"It just feels right": Perceptions of the effects of community connectedness among trans individuals.

Trans individuals (e.g. trans men and women, non-binary, gender fluid) are at higher risk for mental health concerns, in part due to marginalization. Previous work has documented the effects of social support and community engagement on health outcomes. However, individuals' perceptions of community engagement effects may point to opportunities for intervention. This mixed methods study examines trans individuals' perceived effects of participating in trans communities on health outcomes. Semi-structured in-person interviews were conducted with 20 individuals, and 60 individuals participated in cross-sectional online surveys. Perceived discrimination had a strong negative association with self-assessed mental health. Effects of participation included a) positive: contextualization and normalization of experience, self-appraisal, safety, and relief; and b) neutral/negative: energy drain and stigmatization. Effects of not participating included loneliness, depression, isolation, hiding identity, and losing resources. Both discrimination and non-participation in trans communities had negative effects on mental health. Though community participation is often discussed as positive for marginalized populations, it may be important to include possible negative effects (such as energy drain) in research.

Introduction

Trans communities remain an understudied area of research, especially in relation to the effects of community participation and engagement [1]. Trans individuals refer to those whose gender identity differs from societal expectations based on sex assigned at birth (e.g. trans men and women, gender fluid, non-binary). Previous studies of trans individuals are typically focused on transition-related and HIV-related care [2]. Research shows that these individuals are at a higher risk of negative mental health outcomes. These effects may be explained through the minority stress framework, which describes how stress of marginalization within cisnormative (prioritizing and normalizing cisgender, or having one’s gender correspond to their sex assigned at birth) societies can lead to negative health outcomes [3]. Another framework to describe the mental health effects of marginalization of trans people is cisgenderism which “delegitimizes people’s understanding of their genders and bodies” [4, 5]. Discrimination has been found to affect health among trans individuals, both in quantitative (including mental health [6-11] and risk behaviors [12, 13]) as well as qualitative studies (including mental health [14, 15] and health care access [16]). While trans individuals are becoming more visible within society through media and popular culture, these communities continue to experience specific health disparities and stressors. These adversities can prevent trans individuals from achieving their optimal quality of life.

The transgender population experiences stigma and adverse mental and physical health effects at higher rates than their cisgender peers [17, 18]. Specifically, suicide, anxiety, depression, and substance use statistics among transgender individuals are disproportionately high compared to the national average. As of 2015, 48% of respondents reported serious suicidal thoughts in the last 12 months, compared to 4% of the US general population [19]. One-quarter of respondents also reported abusing substances within the last month, as compared to 8% of the US population [19]. Furthermore, depression (44.1%) and anxiety (33.2%) were reported at higher rates than the national averages of 7.1% and 19.1%, respectively [20].

In order to combat these negative health outcomes among trans individuals, protective factors such as community engagement and social support can mitigate negative health outcomes and provide the ability to cope with the burdens of stress and prejudice that trans individuals may experience daily from family, coworkers, and friends [17, 18]. Social support can be categorized in the following ways: emotional, instrumental, appraisal, and informational [21]. Online communities constitute one component of social support. Cipolletta [22] suggests that online communication with other trans individuals can provide safety for disclosing intimate thoughts and advice regarding the transition process while allowing the user to protect their identity. Participants within this study cited experience sharing, asking and offering advice, and building relationships as three of the top motivations for engaging in an online community. Previous research has reported linkages between mental health status and social support among trans people. Lack of support from family and friends, higher risk of cyberbullying, and personal violence are all correlated with negative mental health outcomes for trans individuals [23]. Family can provide fundamental social support that is pivotal to mental health and self-esteem. A lack of familial support and maltreatment from the family unit increased the chances of the trans individual becoming homeless by nearly four times [24]. Self-esteem was also shown to be linked to familial acceptance, with lower familial acceptance associated with, for example, a decreased chance of future gender affirmation medical procedures for those individuals desiring them. This study suggested the implementation of social support networks to create higher self-esteem ratings within the transgender and trans community.

Historically, lesbian, gay, bisexual, trans, and queer (LGBTQ+) individuals have formed or engaged in groups for support, leading and advocating for change, and to celebrate diversity across sexuality and gender [25-28]. This study examines community engagement broadly, including community participation and connectedness. Community connectedness is defined as “the strength of an individual’s affiliation with a group to create a mutually influential relationship and sense of belonging” [29-32]. Pflum’s [18] study of transfemme individuals (those who were not assigned female at birth and present as women or feminine, see [33] for more on this identity) identified that increasing community connectedness and seeking social support are linked to a decrease in adverse mental health effects. In building a connection with a community, trans individuals may seek support for a variety of reasons, and not always from trans-specific communities. One study had participants describe their supportive groups and how these groups aided them. Participants who felt connected to a variety of communities, such as LGBTQ+, religious, and ethnic groups, reported that these groups encourage them when they are feeling “overwhelmed and less resilient,” and having a community to rely on allows them visibility within society [34].

Though definitions of communities vary depending on context, we use a broadly inclusive definition of a shared similarity between group members [35]. Community resilience is a recent shift in understanding various socioecological levels of resilience from individuals and families. Although subjective community experiences among trans individuals have not been described in academic literature, individual experiences of resilience strategies have [34]. Though trans individuals are not monolithic or a single community [36], it may be relevant to examine groups as an important facet of improving health outcomes among this population. The subjective experience of engaging in communities may influence the success of community resilience; in previous research on community resilience, individuals’ sense of community could be used to predict disaster preparedness [37]. Therefore, understanding individuals’ perceptions of community engagement may reveal opportunities for intervention and community approaches.

The purpose of this study is to examine trans individuals’ perceived effects on health outcomes of participating or not in trans communities. We use survey data to examine the effects of discrimination and interview data to examine the effects of trans community participation. As the study is based in a large urban area in the South (Charlotte, NC), it may be important to describe some aspects of the general context. The racial and ethnic breakdown of Charlotte, NC is approximately 42% white, 35% black/African American, 14% Hispanic/Latinx, 6% Asian, 3% other [38]. The city is largely segregated socially by race and ethnicity, with different organizations focused on different groups. There is a prominent and active LGBTQ+ youth organization in the city but no LGBTQ+ support organization for individuals over 21 years of age. Our community partner for this study, Transcend, is a predominantly white local trans organization that holds bi-weekly support meetings both for trans individuals as well as family/partners/friends and has a clothing closet. Other trans spaces in the city at the time of the study include a comic book store and café, a trans women’s support group, HIV service organizations, specific nights at various nightclubs and bars, and annual Pride events.

Materials and methods

This community-based participatory research study used semi-structured interviews (n = 20) and an online survey (n = 60). The interview guide and survey were developed by study authors JB and TL, based on existing literature and preliminary conversations with the community partner, a trans support organization. The community partner’s leadership (two individuals) reviewed the guide and survey and made edits; due to time and financial limitations, we did not conduct a pilot study. Eligibility criteria for both the survey and interviews included being at least 18 years of age, identifying as other than cisgender (e.g. trans, genderqueer, etc.), living in the Charlotte, NC region, and an English speaker. Participants were recruited simultaneously for both methods through word of mouth and social media posts in LGBTQ+ and trans groups. Participants were selected if they met eligibility criteria. All protocols and procedures were approved by the Institutional Review Board of the University of North Carolina at Charlotte.

Potential interview participants were directed to an online screening questionnaire after indicating informed consent electronically. Interviews took place in private rooms within an LGBTQ+ community organization or on the phone for those in extenuating circumstances (e.g. lacking transportation; n = 2). The interviewer was a trans individual familiar with the community, identified by the community partner. Interviews lasted approximately 45 minutes and focused on experiences of community engagement and local trans organizations. Example questions included, “What are the effects on your daily life when you participate in gender diverse groups/services?” and “What are the effects on your daily life when you don’t participate in gender diverse groups/services?” Participants selected their own pseudonyms and these are used in this paper. Participants received a $20 gift card for their participation. All interviews were audio recorded and transcribed verbatim.

Interview transcripts were coded using inductive thematic analyses [39] with Dedoose online qualitative analysis software [40]. Common ideas were grouped together to form “themes.” A codebook was created based on the interview guide and then augmented during initial analyses. Two different trained coders coded each interview such that each interview was coded twice. Reliability was confirmed among the coding team using Dedoose’s test function, with any codes corresponding to a Kappa of less than 0.80 discussed and refined until consensus was reached. Coders used “memo”ing, or digital notes tied to excerpts or interviews, to track their assumptions and biases while coding [41]. Initial analyses were presented as a summary report to the community partner’s leadership for verbal feedback during an in-person meeting.

Surveys were conducted using Qualtrics online software. Survey questions focused on physical and mental health, discrimination, community connectedness, strengths and weaknesses of the community partner organization, and effects of participating with trans communities. Participants received $15 Amazon gift cards for completing the survey.

In addition to the qualitative analysis, a quantitative assessment of the influence of discrimination on both physical and mental health was performed. Survey data was mapped in ordered form so that higher values of the ordered variable were associated with higher levels of the underlying latent construct. A description of this mapping is found in Table 1. A latent variable modeling approach was designed to extract information from the categorical (ordered) survey responses into latent constructs. Associations between latent constructs were explored using the R package lavaan [42]. The latent variable discrimination was constructed from seven ordered responses, defined on a 6-point Likert scale, relating to the topic, and it was used as a latent covariate in regression against self-assessment measures of physical and mental health, defined on a 5-point Likert scale, provided by the respondents.

Table 1

Survey questions regarding discrimination and physical and mental health, as well as the mapping to ordered variables.

ID	Survey Question	Latent Measure	Survey Responses & Ordered Response Mapping
Q1	In your day-to-day life how often have any of the following things happened to you because of your gender identity?—You are treated with less courtesy or respect than other people.	Discrimination	Never = 1Less than once a year = 2A few times a year = 3A few times a month = 4At least once a week = 5Almost every day = 6
Q2	In your day-to-day life how often have any of the following things happened to you because of your gender identity?—You receive poorer service than other people at restaurants or stores.
Q3	In your day-to-day life how often have any of the following things happened to you because of your gender identity?—People act as if they think you are not smart.
Q4	In your day-to-day life how often have any of the following things happened to you because of your gender identity?—People act as if they are afraid of you.
Q5	In your day-to-day life how often have any of the following things happened to you because of your gender identity?—You are threatened or harassed.
Q6	In your day-to-day life how often have any of the following things happened to you because of your gender identity?—People act as if they're better than you are.
Q7	In your day-to-day life how often have any of the following things happened to you because of your gender identity?—You are called names or insulted.
Q8	Thinking about the last 6 months, how would you rate your PHYSICAL health?	Physical Health	Poor = 1Fair = 2Average = 3Good = 4Excellent = 5
Q9	Thinking about the last 6 months, how would you rate your MENTAL health?	Mental Health

Results

A general overview of the themes and subthemes that emerged from this study is included in Table 2.

Table 2

Themes of the effects of discrimination and community connectedness from both qualitative and quantitative methods.

Theme	Subthemes
Perceived effects of discrimination on health	Increased levels of discrimination significantly associated with mental health
General trans community connectedness	Difficult to discern effect on life because:
	1) participants adjusted to stigma in daily life, and/or 2) there’s no distinction of connecting (or not) to trans community
	Level of community engagement varied
Effect of trans community connection:	Feel better
	Social support
Positive
	Normalized and validated experiences
	Freedom of expression
	Safety and relief from risk and stress of life
Neutral	Drains energy while also regenerative
Negative	Hearing others’ negative experiences is triggering
	Being in group of trans individuals can increase perceived stigma
Effects of not connecting with trans community	Feel lonely and guarded
	Begin to isolate socially
	Difficulty finding resources
	Work/daily lives become more encompassing

Effects of discrimination on mental and physical health

Fig 1 shows the graphical representation of the latent variable modeling assessing the impact of perceived discrimination on mental and physical health. A summary of results from this latent variable model is provided in Table 3. All measures of discrimination reported in Table 1, with the first measure set to 1 for identifiability purposes, provided similar, statistically significant contributions to the latent construct, as reflected in Table 3. Negative values of the regression coefficients between perceived discrimination and self-assessed mental and physical health indicate that higher levels of perceived discrimination are associated with lower levels of self-assessed mental and physical health. While both estimated regression coefficients follow that negative pattern, only the one relating to the relationship between perceived discrimination and self-assessed mental health was statistically significant (β = -0.519; p<0.0001).

Fig 1

Graphical representation of the latent variable model, with numbers 1–9 representing the IDs listed in Table 1 regarding the Likert-scale questions in the questionnaire.

Boxed numbers represent the model estimates, as listed in Table 3.

Table 3

Impact of perceived discrimination on self-assessed mental and physical health.

Latent Variable Construction	Estimate	SD	z-value	p-value
Discrimination Q1(Fixed estimate to provide scale)	1.000
Discrimination Q2	1.078	0.072	14.990	<0.0001
Discrimination Q3	1.108	0.061	18.193	<0.0001
Discrimination Q4	1.086	0.058	18.603	<0.0001
Discrimination Q5	1.111	0.070	15.814	<0.0001
Discrimination Q6	1.133	0.073	15.519	<0.0001
Discrimination Q7	1.009	0.075	13.517	<0.0001
Discrimination (Latent)	0.630	0.077	8.217	<0.0001
Regressions:
Physical Health Q8 ~ Discrimination	-0.212	0.151	-1.407	0.159
Mental Health Q9 ~ Discrimination	-0.519	0.130	-3.987	<0.0001

General connectedness

Interview participants in our study were predominantly white (n = 18, 90%), 23–30 years of age (n = 7, 35%), and trans women/feminine (n = 8, 40%) (see Table 4 for participant demographic information). In general, some participants reported it was difficult to discern the effects of connecting with trans groups because they had adjusted to a negative and stigmatizing normality. “I got so used to normal day-to-day life without a lot of exposure to other trans people…So, really it was kind of like living life… as a regular person” (S, 51–60 years, male (female to male; FTM)). Similarly, others had trouble describing effects because there was no distinction between when they felt connected or not to trans groups; these individuals had friends and family who were trans, and they were in nearly constant contact with trans communities. “I’m really fortunate that my husband is trans. […] and I have a trans roommate, and I have another trans partner; so, most days I participate in trans groups, I feel like.” (Max, 23–30 years, non-binary transmasculine)

Table 4

Interview participant demographic information.

Pseudonym	Pronouns	Gender ID	Race/ Ethnicity	Age Range (Years)
Gwen	she/her	transgender woman	white	23–30
Susan	she/her	transgender female	white	31–40
Britney Spears	she/her	trans female	black	23–30
Amy	she/her	MTF trans	white	51–60
Mina	she/her	trans woman	white	23–30
Miranda	she/her	trans woman	white	31–40
Nicole	she/her	trans woman	white	41–50
Wonder Woman	she/her	elder trans woman	white	51–60
Lara	she/her	female	white	41–50
S	he/him	male (FTM)	white	51–60
Cooper	he/him	male (FTM)	white	41–50
Jeff	it/its	genderfluid trans man	white	23–30
Max	they/them	non-binary transmasculine	white	23–30
Mike	he/him	Changes daily but masculineish sometimes	white	18–22
Chaucer	they/them	genderqueer/gender fluid	white	23–30
Elizabeth	she/her	transfeminine nonbinary	white	41–50
Geo	they/them	non-binary	black	18–22
Gio	they/them	non-binary/agender	white	18–22
Jim Henson	they/them	nonbinary	white	23–30
Scotland	they/them	agender	white	41–50

Participants’ level of engagement with trans communities varied, with some more deeply embedded in activism and advocacy and others hardly involved with other trans individuals. Amy (51–60 years, male to female (MTF) trans) spent most of her time disconnected from trans communities: “Considering that I am not out professionally at all, assuming that I’m not working on the weekends, the weekends is all that I have. Weekends and evenings once I get home.” Amy’s disconnection was, in part, tied to her belief that individuals navigate their own paths, but she looked forward to connecting with more trans people through a support group.

Effects of trans community connection

Many participants described their connection as making them feel better, “balanced” (Jim Henson, 23–30 years, nonbinary), or “bolstering their emotional health” (Gio, 18–22 years, nonbinary/agender). Part of this was in relation to contextualizing their experiences.

“It helps me remember, too, that there are other trans people out there and some that are in much worse situations. In general, my transition was good, my family overall was pretty accepting. Work was pretty good. Didn’t lose friends or else they were there at the beginning or kind of phased out.” (S, 51–60 years, male (FTM))

Social support was one of the most predominant effects of trans communities’ connection that participants stated. In addition to having individuals who could understand an asexual identity, Mike (18–22 years, gender changes daily but masculineish sometimes) had identified others who could understand his identities:

“I feel like I can text just about anyone at [community organization] at any time and know that I have a friend to back me up…I’m going to call it intimacy with my friendship, that there is a certain level of people that I can just vibe with and they understand and I don’t have to explain myself every five minutes. They understand. They’ll ask me ‘What are your pronouns? What is your name today? Who is presenting today?’”

One facet of social support can be assisting in self-appraisal. Elizabeth describes seeing themselves as a resource, which may be tiring while also affirming.

“I guess my participation in gender diverse groups or services is very different from someone who relies on them as a resource, because in many cases I am the resource. My phone goes off constantly. There’s always somebody popping up in my messenger.” (Elizabeth, 41–50 years, transfeminine nonbinary)

Their networks were constructed through involvement in trans communities.

Trans community connections normalized and validated participants’ experiences. Online communities were helpful for general information finding (such as hormone advice) and for a wide variety of identities.

“I was really afraid to transition for a long time because I thought that because my sister is trans, because my partner is trans, that it wasn’t okay for me to also be trans. And I think that hearing from other trans people, that’s another place where the internet portion comes in, because there’s not a whole lot of people in the whole world whose sibling is also trans. But if you’re going to find them, you will find them online and I’m not the only one and that’s pretty encouraging.” (Jeff, 23–30 years, genderfluid trans man)

The mere fact of others’ existence was enough to normalize a wide range of experiences.

“It was enough confirmation that there were other people, that it wasn’t necessarily something that I needed for support. At the same time, I was just transitioning and I just had some chest surgery, so it was kind of a confirmation or affirmation of who I was… but something that, ‘wow, there are other people like me.’” (Cooper, 41–50 years, male (FTM))

Similarly, participants described a freedom of expression in their communities not only in identity and appearance but also ideas. “I just like scrolling through my feed and it’s nice…I like seeing content that is both body and size positive and trans positive ‘cause that’s something that I struggle with.” (Gio, 18–22 years, nonbinary/agender) This was related to participating in both online, as well as virtual, groups (such as a local trans community Discord group, a chat app that allows users to create anonymous profiles).

“Through the Facebook page, it was always kind of tough. I did some through the messenger there. For some reason, that didn’t seem as ‘let your hair down’ kind of thing. Whereas [with] the Discord server, I jump on and I’m part of any conversation I want to be in and they know me and I know them and it’s more of a conversation.” (Nicole, 41–50 years, trans woman)

They could also learn about others’ gender diversity through the full range of identities participating in their communities.

Unsurprisingly, participants often described feeling safety and relief from the risks and stress of their lives outside of trans communities. “I know that I have something that week where I can comfortably be myself; so, even if I am having one of those terrible days at work or with my parents, then I at least have that relief coming.” (Chaucer, 23–30 years, genderqueer/gender fluid) For Max (23–30 years, nonbinary transmasculine), this was relief from constantly having to be the only trans, or even LGBTQ+, person at work or in spaces, “I’m usually the only trans person in a room and that’s exhausting; so, I love being around other trans people who are just living their lives, and I’m like ‘Thank God.’”

Not all of the effects of participation were fully positive. One neutral effect was the drain of social interaction, though trans community participation was also regenerative. “While I can’t come to [community organization] every week because of my social battery,…going to gender diverse groups gives me energy a lot. It takes energy to get here, but it gives me energy in return.” (Mike, 18–22 years, gender changes daily but masculineish sometimes) There were two types of negative effects identified by participants. The most common was that hearing others’ similar negative experiences (such as stigma or family trouble) was triggering, and participants sometimes felt exhausted or sad because of the triggers.

“For the most part, I am happy around my friends and we love to joke around and talk about different issues or even just bitch about life and some of the stuff that sucks about being trans. Sometimes it can have a negative effect on me where it’s more, so bittersweet.” (Gwen, 23–30 years, transgender woman)

Moreover, action steps in relation to these negative experiences were often not discussed.

“I find that when we are just getting together and having fun, I find those like really, really refreshing. And I do want to seek out spaces where trans people are trying to learn how to cope with trauma, but I haven’t found a space that does it in a way that I think is actually healthy.” (Max, 23–30 years, nonbinary transmasculine)

A second negative effect was that being in a group of trans individuals in public can be more stigmatizing than just being by oneself.

“All of us being gender diverse, when we are in groups together, it can be like, we go out and we’re harassed. Or people give you a microaggressive look, or they stare. And that can be stressful if I’m going out like, ‘Do I need to prepare myself? What am I going to do if someone misgenders my friend?’” (Geo, 18–22 years, nonbinary)

Effects of not connecting with trans communities

Nearly universally, participants said that when they did not connect with trans communities or groups, they felt lonely. “I get depressed. I get very—I don’t want to say irritable, but I get very sensitive to things.” (Nicole, 41–50 years, trans woman) Participants also described feeling more guarded. “I become a little bit [more] guarded. I’m more comfortable and at ease amongst those of my own kind, basically.” (Wonder Woman, 51–60, elder trans woman)

Participants said that when they felt less connected to trans groups or communities, they began to isolate themselves in general. “I am just kind of like, more reclusive and lonely ‘cause coming to [community organization] right now is one of my main social outlets. So, I would just be kind of a shut in.” (Mina, 23–30 trans woman) This isolation resulted in the loss of relationships for some, like Susan. “I kind of lose touch. I isolate. I do forgo and sometimes get way too lost and everything else…so, the loss there is just really relationships.” (Susan, 31–40, transgender female) More specifically, some participants said they began “hiding” in relation to their gender identity, as Nicole (41–50 years, trans woman) says, “I go back into hiding once I leave here.” This ‘hiding’ meant not expressing themselves as fully, or correcting people when they are misgendered. Participants described this as detrimental and grief-causing. Scotland reported feeling “shitty” when they are less connected and do less advocacy for themselves.

“The lack of participating in these groups is what gets me. It irks me, and I know a lot of it is on me, but I always have this kind of itty bitty internal knee jerk when anyone refers to me as ‘Mr’ or use male pronouns. But part of the reason they do is because I haven’t corrected them. And the reason I haven’t corrected them is, frankly, I don’t want my head broken and I want my contract renewed… And that’s a shitty way of hiding in the patriarchy.” (Scotland, 41–50 years, agender)

Related to isolation, participants had trouble finding resources in the community because they were less connected with trusted individuals to whom they could turn for ideas and referrals. S described what would be lost if he was not connected with other trans individuals in the community.

“[Local groups are] good for local resources, because sometimes you look for resources and either you can’t find it in your area or it’s dated or the doctor is no longer practicing or has moved. So it’s nice here that you have all of that information you can access and it’s local and its current.” (S, 51–60 years, male (FTM))

When they were not as connected to trans communities, participants’ work or daily lives became more encompassing. This was often described as problematic because these spaces were stigmatizing or non-affirming.

“As long as I’m focused on my work, it’s what my brain thinks. But not being out at work a lot can cause some grief, you know. Especially with like, going to the restroom, so I don’t do the wrong one. [Laughter] Or you go out to lunch with the other coworkers and not being recognized as the woman that I am can sting a little bit.” (Amy, 51–60 years, MTF trans)

Participants also described a general disconnectedness. This included missing the community conversations, but also a general feeling of something being wrong.

“I am missing out on part of my community who I should be around. It’s like we affirm each other. Like each other’s existence and just being around each other. And when I don’t have it, something is missing, it’s not right.” (Geo, 18–22 years, nonbinary)

Discussion

This study provides evidence of positive effects from community connectedness for trans individuals. The vast majority of participants reported that they noticed the effects on their lives when they did or did not participate in trans communities. Participants described effects on their own mental health, but also how community engagement built their social support networks which may be an important aspect of resilience. Previous reviews have documented how community engagement positively affects physical and psychological health [among African American women, 43], self-confidence, self-esteem, sense of personal empowerment, and social relationships [44]. Participants were less likely to describe effects that were prosocial, or focused on helping others; though a few participants mentioned that they were a resource for others, they did not discuss this as a benefit. Other studies have found cultivating empathy and providing support to others as themes of community support among trans individuals [45].

Hendricks and Testa [46] report that disclosing gender identity may facilitate community resource utilization. Given that participants in our study discussed learning about gender identities and receiving self-appraisal support, they may be navigating their own gender identity. Thus, the barrier of self-disclosure may be problematic for those who most need community. In other words, trans individuals without language to talk about their gender identity may be less able to access community yet in need of resources and support.

Participants in our study described some negative effects of engaging in trans communities, such as being triggered by negative events or emotions that were similar to their own. Other work with trans individuals found competition in groups, of being “trans enough” [45]; participants in the current study did not discuss this, in part perhaps due to the diversity of gender identities present in the group. In community organizing or support, it may be important to build skills around coping with vicarious trauma [occuring from working with individuals with trauma; 47]. Or, as Max discussed, ensuring that trans individuals have different ways of interacting other than sharing negative experiences. As Mike described the energy drain of participating in groups, this may have implications for collective action. Previous work has identified how trans people of color can be drained from activism efforts [25, 48]. This may be tied to findings that higher levels of antitrans discrimination are associated with collective action [49].

Emotional support was the most common benefit from community participation, and reported as a loss when not participating in trans communities. This was described as validation, freedom of expression, and empowerment. Furthermore, participants described informational support in obtaining referrals for local providers or resources; this can also be described as “investing in community knowledge” [45] as individuals continue to share this awareness within and among trans groups.

Matsuno and Israel’s [50] transgender resilience intervention model highlights community resilience and intervention opportunities for trans individuals. Group interventions include group therapies and support groups, mentoring programs, and/or family/couples’ therapy. As many participants in our study appreciated learning about other trans identities as well as describing being triggered by others’ experiences, interventions that offer distraction, are socially focused, or non-therapy focused (such as outings to restaurants or game nights) may be important interventions for positively supporting trans individuals. Further, Case and Hunter [51] describe the power of “counterspaces” in supporting positive adaptation for marginalized individuals by “challenging deficit-oriented narratives.” We find evidence of all of the counterspace framework domains: narrative identity work in which participants described learning about others’ identities, acts of resistance in which participants described the value of freedom of expression that are not sanctioned in larger society, and direct relational transactions in which individuals offer social support, safety, and security.

Trans community interventions may expand outside of in-person modalities, including virtual and online. As Metthe [45] points out, online communities are a key part of trans social support. Though we did not specifically ask about online networks, many participants in this study differentiated the benefits of in-person communities (deeper connections, being known), virtual communities such as Discord chats (easy access, anonymity, local knowledge), and online communities (wide range of individuals, numerous communities). In localities where individuals have limited transportation access or with widespread geographic areas, virtual and online communities may become more salient.

In addition to the qualitative analysis of connectedness, we identified a strong quantitative association between perceived discrimination and self-assessed mental health; though, a similar statistically significant result was not confirmed for the association between perceived discrimination and physical health. This relationship between discrimination and mental health is reported in other samples of trans individuals [5, 52]. This may be a factor of both a potentially weaker negative association between perceived discrimination and physical health, as well as the smaller sample size of the study. Within the qualitative results, we see participants more focused on mental health impacts than physical health; the one subtheme that connected with physical health was that participants had difficulty finding resources (including healthcare providers) when they were less connected to the trans community. The impact on self-assessed mental health of any perceived discrimination, and the potential impact (primary or secondary) of this association on self-assessed physical health, should grant further study in this area. These results serve a dual purpose: (1) they provide further evidence of the hypothesis that discrimination has a negative impact on mental health; and (2) they can serve as a pilot or feasibility study, providing measurable outcomes that can help assess statistical power in future studies on the impact of discrimination on both physical and mental health within the trans community.

Strengths and limitations

This study used community-based participatory research approaches and a diverse research team, which may have increased the validity of our findings. However, as most participants were connected to the community partner, our findings may reflect experiences of trans individuals who are more involved in trans communities. Because all in-person interviews were conducted at the community partner location, this may have excluded the experiences of those uncomfortable with the organization. Individuals who are less connected may not notice or experience the same benefits of participating in trans communities. Interview participants were mostly younger and white, in part due to our community partnership and recruitment through social media.

Interview questions.

(DOCX)

Click here for additional data file.

12 May 2020

PONE-D-20-00790

“It just feels right”: Perceptions of the effects of community connectedness among gender diverse individuals

PLOS ONE

Dear Dr. Bowling,

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.

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Academic Editor

PLOS ONE

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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. When reporting the results of qualitative research, we suggest consulting the COREQ guidelines: http://intqhc.oxfordjournals.org/content/19/6/349. In this case, please consider including more information on how participants were selected; if a pilot study was tested; how data was coded; if bias issues were considered.

3. Please endure that the statements made at lines 109 to 111 are supported by references. Moreover, please state the name of the community partner mentioned at line 112.

4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated.

5.  We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

Additional Editor Comments (if provided):

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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: Yes

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: 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: 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: No

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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: Comments to author

The abstract summarizes the study in a comprehensive manner.

Introduction:

Good review of the pertinent literature.

Line 40 I would remove “to be” after “remains”

The sentence starting by “Self-esteem” on line 76 presents pertinent information but may be perceived as too binary in its orientation. The sentence recounts the results from a study performed in 2018 and speaks to lack of familial acceptance decreasing the chance of completing sex reassignment surgery. Not all gender diverse individuals choose to undergo surgery and in fact many don’t want it. Therefore, completing surgery is not a required part of the self definition of one’s gender. The sentence appears to indicate the contrary. The authors may want to rethink how they present this data.

Material and Methods

In my opinion this is the part of the manuscript that needs the most work. The authors have used a mixed method approach. The quantitative portion of the study uses a questionnaire that was devised de novo and which has not been validated. The sentence starting by “The initial” on line 119 briefly states that the interview guide and survey were informed by “the community partner”. This is all that is said about how these two instruments were developed. We need more information on that process. E.g. By whom and how were the questions used in the interview guide and survey originally drafted? Was this based on existing literature? What does “informed by the community partner” mean exactly? Were only one or two people consulted, was it a committee? How were these individuals chosen to give their opinion? Did they suggest questions, some or all? Did they read and say, yes that sounds fine”

As stated in line 127 and 128 the interviews occurred at a LGBTQ+ community organization. This may have led to individuals not wanting to participate as they may not have wanted to be seen entering such an area. This is not mentioned in the limitations and it should.

The authors present a good description of their coding process, but some items need to be clarified. In Line 136 it is mentioned that “Each interview was coded twice by a trained coder”. This is not clear to me. Does this mean that the interview was coded by two different coders? Or twice by the same coder? As it is written it seems to be the latter. Is this right? They also mention in line 138 that they presented the initial analyses to the community partner for feedback. How as this done, to how many people, where they the same as those that participated in generating the questions, how was feedback gathered and integrated?

In summary I would suggest that their should be a more detailed description of what exactly is meant by participatory research and how it took place and a more detailed description also be given on how the interview guide and survey questions were devised.

Results

I like this section as it presents the data in a clear manner. On line 163 a Table 3 is mentioned the description of its content does not correspond to the Table 3 included in the manuscript. Hence this table appears to be missing. In line 301, the word “shitty” is a participant comment and should be in italics. It may be helpful to include a table with the main themes and the subthemes.

Discussion

This is good and supported by the results.

Reviewer #2: A very interesting and useful topic. However, the language standard across the board requires significant improvement, specifically around sentence structure, grammar, and in-text citation style. This paper is also quite undercited - would have done good to look at some of the work being done by Damien Riggs, Gavi Ansara, Shoshana Rosenberg, JR Latham and others. The arguments are not very well-supported by the literature provided, and lack nuance and critical assessment. There is also lack of clarity around a lot of the language being used e.g. "transfemmes", which might be somewhat common nomenclature in community but does not provide adequate description of what group of people is being addressed.

From a methodology standpoint, I'm not convinced 60 participants is enough for a quantitative component. Certainly it is a very limited number in terms of appropriate levels of power and validity. This section feels like it does not necessarily help to support your argument, at least not in its current form.

Having said all that, there is some fantastic data in here that would be very interesting if it underwent some further analysis and was sufficiently linked to current literature. Very interesting to talk about energy drain as a concept, something that requires more research and attention, particularly as we see more and more researchers engage the trans community for labour in the form of consultancy. I would be interested to see the qualitative interview protocol in particular, as it still seems like the questions could have been more nuanced and yielded some more in-depth data than what is presented here.

I believe this paper has some potential, but needs to be a) reviewed by a more senior academic for grammar, format, and syntax, and b) reconsider the methodological/analytical focus. While there's always some need for further data on discrimination, a 60-person survey does little to support your standpoint. You may be better off turning this into a purely qualitative analysis paper using the interview data on its own, particularly as the quant data points do not appear to be linked to the topic of the paper overall.

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Reviewer #1: No

Reviewer #2: No

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3 Jun 2020

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: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

We appreciate the reviewers’ positive commentary on our statistical analyses.

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

Though this data comes from a larger dataset, all relevant excerpts are available at https://www.openicpsr.org/openicpsr/project/117143/version/V1/view.

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: No

We have conducted a thorough spelling and grammar review of the manuscript and corrected mistakes.

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: Comments to author

The abstract summarizes the study in a comprehensive manner.

Introduction:

Good review of the pertinent literature.

We appreciate the reviewer’s positive comment of our literature review.

Line 40 I would remove “to be” after “remains”

We have corrected this as suggested.

The sentence starting by “Self-esteem” on line 76 presents pertinent information but may be perceived as too binary in its orientation. The sentence recounts the results from a study performed in 2018 and speaks to lack of familial acceptance decreasing the chance of completing sex reassignment surgery. Not all gender diverse individuals choose to undergo surgery and in fact many don’t want it. Therefore, completing surgery is not a required part of the self definition of one’s gender. The sentence appears to indicate the contrary. The authors may want to rethink how they present this data.

We appreciate the reviewer pointing out this oversight. We have changed the sentence as follows, “Self-esteem was also shown to be linked to familial acceptance, with lower familial acceptance associated with, for example, a decreased chance of future gender affirmation medical procedures for those individuals desiring them.”

Material and Methods

In my opinion this is the part of the manuscript that needs the most work. The authors have used a mixed method approach. The quantitative portion of the study uses a questionnaire that was devised de novo and which has not been validated. The sentence starting by “The initial” on line 119 briefly states that the interview guide and survey were informed by “the community partner”. This is all that is said about how these two instruments were developed. We need more information on that process. E.g. By whom and how were the questions used in the interview guide and survey originally drafted? Was this based on existing literature? What does “informed by the community partner” mean exactly? Were only one or two people consulted, was it a committee? How were these individuals chosen to give their opinion? Did they suggest questions, some or all? Did they read and say, yes that sounds fine”

We agree that this detail was an important omission from the methods section. We have revised this section and added the following, “The interview guide and survey was developed by study authors JB and TL, based on existing literature and preliminary conversations with the community partner, a GD support organization. The community partner’s leadership (two individuals) reviewed the guide and survey and made edits.”

As stated in line 127 and 128 the interviews occurred at a LGBTQ+ community organization. This may have led to individuals not wanting to participate as they may not have wanted to be seen entering such an area. This is not mentioned in the limitations and it should.

Upon review, we have added information about two of the interviews that were conducted over the phone instead of at the community organization. “Interviews took place in private rooms within an LGBTQ+ community organization or on the phone for those in extenuating circumstances (e.g. lacking transportation; n=2).” In the limitations section, we have added this as a limitation. “Because all in-person interviews were conducted at the community partner location, this may have excluded the experiences of those uncomfortable with the organization.”

The authors present a good description of their coding process, but some items need to be clarified. In Line 136 it is mentioned that “Each interview was coded twice by a trained coder”. This is not clear to me. Does this mean that the interview was coded by two different coders? Or twice by the same coder? As it is written it seems to be the latter. Is this right?

We have revised this language for clarity to read, “Two different trained coders coded each interview such that each interview was coded twice.”

They also mention in line 138 that they presented the initial analyses to the community partner for feedback. How as this done, to how many people, where they the same as those that participated in generating the questions, how was feedback gathered and integrated?

We have included additional detail in this section as “Initial analyses were presented as a summary report to the community partner’s leadership for feedback in an in-person meeting.”

In summary I would suggest that their should be a more detailed description of what exactly is meant by participatory research and how it took place and a more detailed description also be given on how the interview guide and survey questions were devised.

We appreciate the reviewer’s request for more detail on what participation looked like, and we have addressed the aforementioned comments, as indicated above, to present these details in the revised manuscript.

Results

I like this section as it presents the data in a clear manner. On line 163 a Table 3 is mentioned the description of its content does not correspond to the Table 3 included in the manuscript. Hence this table appears to be missing.

We have corrected this to refer to the right table and thank the reviewer for drawing our attention to this mistake.

In line 301, the word “shitty” is a participant comment and should be in italics.

We have put the word in italics as suggested.

It may be helpful to include a table with the main themes and the subthemes.

We have added in Table 2 with the main themes and subthemes.

Discussion

This is good and supported by the results.

We appreciate the reviewer’s compliment.

Reviewer #2: A very interesting and useful topic.

We thank the reviewer for pointing this out. We agree that more strengths-based approaches are needed.

However, the language standard across the board requires significant improvement, specifically around sentence structure, grammar, and in-text citation style.

We have conducted a thorough grammar and spelling review and corrected language as needed. However, we, of course, cannot correct language from direct quotations transcribed from the interview participants. We used Vancouver citation style, and all of our in-text citations appear to be in the correct format, as per PLOS One guidance to authors.

This paper is also quite undercited - would have done good to look at some of the work being done by Damien Riggs, Gavi Ansara, Shoshana Rosenberg, JR Latham and others. The arguments are not very well-supported by the literature provided, and lack nuance and critical assessment.

We thank the reviewer for drawing our attention to these authors. We have added the following to the Introduction: “Another framework to describe the mental health effects of marginalization of trans people is cisgenderism which “delegitimizes people’s understanding of their genders and bodies” [4, 5].” And in the Discussion, “This relationship between discrimination and mental health is reported in other samples of GD individuals [5, 38].” We have also added the following to augment our assessment in the Discussion section: “Further, Case and Hunter [37] describe the power of “counterspaces” in supporting positive adaptation for marginalized individuals by “challenging deficit-oriented narratives.” We find evidence of all of the counterspace framework domains: narrative identity work in which participants described learning about others’ identities, acts of resistance in which participants described the value of freedom of expression that are not sanctioned in larger society, and direct relational transactions in which individuals offer social support, safety, and security.”

There is also lack of clarity around a lot of the language being used e.g. "transfemmes", which might be somewhat common nomenclature in community but does not provide adequate description of what group of people is being addressed.

We have added language to describe a meaning of transfemme as follows, “Pflum's [7] study of transfemme individuals (those who were not assigned female at birth and present as women or feminine, see [22] for more on this identity)…”

From a methodology standpoint, I'm not convinced 60 participants is enough for a quantitative component. Certainly it is a very limited number in terms of appropriate levels of power and validity.

Sampling from the trans/genderqueer/etc. population is oftentimes logistically complex and financially costly versus sampling from the overall population, with the additional complexity of limited literature to inform sample sizes a priori. There is no ‘minimal clinical importance difference’ to be defined in the context of the impact of discrimination on health and to inform an effect size. The hypotheses in this manuscript were not based on thresholds of minimal importance, but instead on whether there was any association between discrimination and self-assessed measures of health. Setting such a non-zero threshold would be ethically questionable, as it would classify some levels of the impact of discrimination on health as no evidence of such impact.

Sixty participants were sufficient to detect a significant, negative association between discrimination and perceived mental health (p<0.0001). There was some weak evidence of a potential negative association with physical health (p=0.159), as well. However, the sample size was, as mentioned in the manuscript, insufficient for the physical health measure given the observed variability to reach similar conclusions (if there is, indeed, such association, which of course we cannot claim).

Ultimately, this quantitative subsection can inform the reader and future researchers. Removing these findings from the manuscript would be detrimental for several reasons:

a) There is a statistically significant negative association between discrimination and self-assessed mental health among the population of focus in our study. This is an important finding that complements the existing literature and reinforces the need for health-driven action in this area, in particular for this highly-discriminated population. The evidence was overwhelming (p<0.0001) even with a reduced sample size. P-values have an embedded adjustment for sample sizes (usually by a factor of sqrt(n)). Smaller samples, therefore, require even further evidence to demonstrate statistical significance.

b) Even though significant evidence of an association between discrimination and self-assessed physical health was not found (if it exists), providing these findings in a quantitative fashion can serve to power future studies.

c) Non-significant findings across multiple independent studies can result in significant findings from a meta-analytic standpoint. Meta-analyses rely on usage of all studies, not only those with significant findings.

d) Ultimately, it is of ethical relevance to report all results, regardless of significance. Reporting results based on whether statistical significance is found would lead to p-hacking/selective reporting, which is a risk that would hurt disproportionally the under-researched populations or those suffering more subtle impacts.

This section feels like it does not necessarily help to support your argument, at least not in its current form.

We have added language to tie the quantitative component with the qualitative results:

In the Introduction: “Discrimination has been found to affect health among GD individuals, both in quantitative (including mental health [6-11] and risk behaviors [12, 13]) as well as qualitative studies (including mental health [14, 15] and health care access [16]).” And, “We use survey data to examine the effects of discrimination and interview data to examine the effects of GD community participation.”

In the Discussion: “Within the qualitative results, we see participants more focused on mental health impacts than physical health; the one subtheme that connected with physical health was that participants had difficulty finding resources (including healthcare providers) when they were less connected to the GD community.”

Having said all that, there is some fantastic data in here that would be very interesting if it underwent some further analysis and was sufficiently linked to current literature. Very interesting to talk about energy drain as a concept, something that requires more research and attention, particularly as we see more and more researchers engage the trans community for labour in the form of consultancy.

We thank the reviewer for the compliment and agree that there are several very interesting ideas that come up within this work.

I would be interested to see the qualitative interview protocol in particular, as it still seems like the questions could have been more nuanced and yielded some more in-depth data than what is presented here.

This manuscript focuses on one segment of the interview, while we have others in press and under review that address other components of the study. We have added two example questions relevant to this manuscript’s analyses, “Example questions included, “What are the effects on your daily life when you participate in gender diverse groups/services?” and “What are the effects on your daily life when you don’t participate in gender diverse groups/services?””

I believe this paper has some potential, but needs to be a) reviewed by a more senior academic for grammar, format, and syntax, and b) reconsider the methodological/analytical focus. While there's always some need for further data on discrimination, a 60-person survey does little to support your standpoint. You may be better off turning this into a purely qualitative analysis paper using the interview data on its own, particularly as the quant data points do not appear to be linked to the topic of the paper overall.

Since this is a summary of prior comments, please note that we have addressed these issues throughout earlier comments provided (see above responses).

Submitted filename: Response to reviewers - 5.27.docx

Click here for additional data file.

3 Aug 2020

PONE-D-20-00790R1

“It just feels right”: Perceptions of the effects of community connectedness among gender diverse individuals

PLOS ONE

Dear Dr. Bowling,

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.

==============================

Thank you for your updated submission, which is nearly ready for acceptance. Please see the reviewer's comments below regarding updating and consistency of language with regard to the subjects of your study. Once those minor revisions are complete, we look forward to accepting your article.

==============================

Please submit your revised manuscript by Sep 17 2020 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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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'.

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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

We look forward to receiving your revised manuscript.

Kind regards,

Amy Michelle DeBaets, PhD

Academic Editor

PLOS ONE

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

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 #2: (No Response)

**********

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 #2: Yes

**********

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

Reviewer #2: 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 #2: 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 #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 #2: Some great improvements on this paper. My remaining concerns are about the use of GD rather than trans or TGD as the overall population descriptor. GD seems to be slowly falling out of favour, and certainly in the realm of trans research overall, "trans"/"transgender" is the most appropriate title used when discussing these communities. I also noticed that "gender nonbinary" is still being used, which is generally a misnomer. "Non-binary" (without the word "gender" in front) is the most accepted gender descriptor in the majority of research in the area. So the first line of the abstract, for example, might read better as:

"Trans people (e.g. trans men and women, nonbinary and gender fluid people) are at higher risk for..."

Otherwise the paper is looking good, and once these little bits are fixed it should make for a good contribution.

**********

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 #2: 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.

3 Aug 2020

Comments to the Author

Reviewer #2: Some great improvements on this paper. My remaining concerns are about the use of GD rather than trans or TGD as the overall population descriptor. GD seems to be slowly falling out of favour, and certainly in the realm of trans research overall, "trans"/"transgender" is the most appropriate title used when discussing these communities. I also noticed that "gender nonbinary" is still being used, which is generally a misnomer. "Non-binary" (without the word "gender" in front) is the most accepted gender descriptor in the majority of research in the area. So the first line of the abstract, for example, might read better as:

"Trans people (e.g. trans men and women, nonbinary and gender fluid people) are at higher risk for..."

Otherwise the paper is looking good, and once these little bits are fixed it should make for a good contribution.

We appreciate the reviewer’s assistance with pointing out language changes and evolution. We have updated “gender diverse” to “trans” throughout the paper, and we have removed “gender” in front of “gender nonbinary” in the parenthetical descriptions.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

24 Sep 2020

“It just feels right”: Perceptions of the effects of community connectedness among trans individuals

PONE-D-20-00790R2

Dear Dr. Bowling,

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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25 Sep 2020

PONE-D-20-00790R2

“It just feels right”: Perceptions of the effects of community connectedness among trans individuals

Dear Dr. Bowling:

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