Well-being during COVID-19 pandemic: A comparison of individuals with minoritized sexual and gender identities and cis-heterosexual individuals.

BACKGROUND: Preliminary empirical data indicates a substantial impact of the COVID-19 pandemic on well-being and mental health. Individuals with minoritized sexual and gender identities are at a higher risk of experiencing such negative changes in their well-being. The objective of this study was to compare levels of well-being among cis-heterosexual individuals and individuals with minoritized sexual and gender identities during the COVID-19 pandemic.
METHODS: Using data obtained in a cross-sectional online survey between April 20 to July 20, 2020 (N = 2332), we compared levels of well-being (WHO-5) across subgroups (cis-individuals with minoritized sexual identities, individuals with minoritized gender identities and cis-heterosexual individuals) applying univariate (two-sample t-test) and multivariate analysis (multivariate linear regression).
RESULTS: Results indicate overall lower levels of well-being as well as lower levels of well-being in minoritized sexual or gender identities compared to cis-heterosexual individuals. Further, multivariate analyses revealed that living in urban communities as well as being in a relationship were positively associated with higher levels of well-being. Furthermore, a moderation analysis showed that being in a relationship reduces the difference between groups in terms of well-being.
CONCLUSION: Access to mental healthcare for individuals with minoritized sexual and gender identities as well as access to gender-affirming resources should be strengthened during COVID-19 pandemic. Healthcare services with low barriers of access such as telehealth and online peer support groups should be made available, especially for vulnerable groups.

Introduction

In December 2019, the novel virus SARS-CoV-2 (COVID-19) was detected. About 13 months later more than 93 million people have been infected by COVID-19 and more than 2.5 million people died by February 2021 [1]. On 24th January 2020 the first case of COVID-19 has been reported in Germany [2]. The World Health Organization (WHO) designated COVID-19 as a Public Health Emergency of International Concern on 30th January 2020. On 11th March 2020 the WHO declared COVID-19 a pandemic. By the time of writing in April 2021, the covid-19 pandemic reached a level of humanitarian crisis. To decelerate the rapid transmission of COVID-19, many non-pharmacological interventions were enforced as a way to control the pandemic. On 22nd March the first measures of social isolation including home confinement were declared by the German federal states. Quarantine is a proven and successful measure to combat infectious diseases (e.g., Ebola); still, the global extent of confinement has never been higher [3]. Accordingly, the socioeconomic consequences of the COVID-19 pandemic in Germany have been significant. There has been an increase in unemployment, an economic recession, and an increase in social inequality, e.g. in income, education [4], and health [5]. Public support programs by the federal and state governments attempted to mitigate these consequences. Among several economic funding schemes for companies to prevent insolvency, the government offered financial aid for employees in receipt of a reduced salary, as well as financial aid for families and students in need [6-8]. COVID-19 and the containment measures have led to significant changes in certain lifestyle behaviors as well as in life satisfaction and general well-being [9-11]. Up to now, most of the research on the COVID-19 pandemic has focused on physical health. Literature shows a significant effect of the COVID-19 pandemic on daily living with an impairment in quality of life and an increase in uncertainty of the present and the future, distress, fear and panic [12]. This has negative effects on well-being and mental health with an increase of emotional disorders [11,13-15].

In general, mental distress and acute symptoms such as apprehension, stress, depression, panic or anxiety, and chronic symptoms such as insomnia and post-traumatic stress disorder (PTSD), have increased since the COVID-19 pandemic [12,16,17]. Individuals with minoritized sexual and gender identities like lesbian, gay, bisexual, trans*, non-binary, queer, inter* and asexual (LGBTQIA*) constitute a particularly vulnerable social and medical group. Past research acknowledges that individuals with minoritized sexual and gender identities experience greater health disparities compared to heterosexual and cisgender individuals, respectively [18]; gender minority people stand out as particularly vulnerable within the LGBQTIA* group [19-21]. These health disparities are understood to be consequences of minority stress due to social disadvantages, discrimination and stigmatization in all areas of life [22,23]. Conceptual frameworks, such as the Minority Stress Model, explain the association between discrimination, social stress, and mental health among LGBTQIA* communities [24,25] The Minority Stress Model postulates that individuals belonging to minoritized groups are exposed to unique stress related to their race, gender or sexual orientation. The model includes external distal minority stressors such as discrimination or exposure to violence as well as internal proximal minority stressors such as expectations of rejection or internalized stigma. As protective factors against minority stress, the model includes social support and community connectedness [20,24,25]. Over the last years, research on needs and mental health of LGBTQIA* is increasing [26]. Overall, the incidence of mental health disparities and psychological disorders such as depression, anxiety disorders, suicidality, and substance abuse was often found to be significantly higher among LGBTQIA* individuals compared to the non-LGBTQIA* population [27-29], in particular among individuals with minoritized gender identities [19,20,30]. In Germany, the legal situation of minoritized sexual and gender identities has improved during the last years. The General Equal Treatment Act of 2006 prohibits unequal treatment based on sexual orientation and gender in civil and labor law [31], whereby trans* and inter* persons are explicitly included in the gender clause. In addition, since 2011, trans* individuals are able to change their gender registration without having undergone gender reassignment surgery involving forced sterilization. In 2017, marriage was opened to same-sex couples, also granting adoption rights to same-sex couples. Since 2018, the German state recognizes the third gender entry "diverse" in addition to "male" and "female", particularly aimed at inter* people [31]. At the same time, however, there has been an increase in anti-LGBTQIA* crime and a strengthening of right-wing populism. Corresponding political parties fight against diversity and LGBTQIA* rights and propagate traditional gender roles [32]. Crises such as the COVID-19 pandemic and resulting trauma put individuals with minoritized sexual and gender identities at a higher psychological risk of decreased well-being and exacerbation of preexisting mental health problems [33,34]. Barriers to medical care in the context of COVID-19 include, among others, a lack of access to LGBTQIA*-friendly medical care, psychotherapy and social support groups in general, and for those seeking gender-affirming healthcare and services in particular [11]. Despite the well-documented vulnerabilities of LGBTQIA* individuals, so far, there is no empirical work published that focused on a comparison of psychological needs, general well-being and risk or protective factors during the COVID-19 pandemic among people with minoritized sexual and/or gender identities and cis-heterosexual individuals. Yet, it is crucial to act immediately in response to the effects of the COVID-19 pandemic on well-being and mental health, in particular for vulnerable social groups such as individuals with minoritized sexual and gender identities. Further, it is of great interest to explore the role of general protective factors for well-being and mental health such as age [35,36], employment [35], partnership status [37,38], place of living [39,40], and children [38] during the COVID-19 pandemic.

Aim of the present study

The present study aims to examine the impact of the COVID-19 pandemic and the precautionary social isolation measures in Germany on current well-being of individuals with minoritized sexual and gender identities (LGBTQIA*) and cis-heterosexual individuals. Thereby, particular attention is paid to heterogeneity within the larger LGBTQIA* group by comparing cis- and trans* individuals to one another, regardless of their sexual orientation; and by drawing within-group comparisons regarding sexual orientation (i.e., comparing cis-lesbian- or gay-identifying individuals to cis-bisexual individuals). Further, general protective and risk factors associated with well-being for all individuals will be examined. Based on previous literature, the following hypothesis are proposed: Levels of well-being in the overall population in Germany have decreased during the COVID-19 pandemic compared to levels before the COVID-19 pandemic (Hypothesis 1), and levels of well-being are lower among all LGBTQIA* populations (cis-individuals with LGBQA* identities and individuals with minoritized gender identities) compared to a cis-heterosexual population (Hypothesis 2). Further, we examined whether age, residential environment, employment status, relationship status, parenthood and COVID-19 status are associated with well-being and the sexual and gender identity (Research Question). Based on our results, we derive recommendations for healthcare providers and public policy makers.

Materials and methods

Setting, study design and sample

An anonymous nationwide online cross-sectional survey was conducted, using SoSci Survey as a platform. The survey was administered in German language and shared via online invitations, where people were invited to partake in a survey on sexuality and family planning during the Covid-19 crisis. Between April 20 to July 20, 2020, a link with access to the survey was distributed in social communication networks on FacebookTM, InstagramTM, TwitterTM and WhatsappTM. We posted invitations to the questionnaire on national social and communication groups on FacebookTM as online bulletin boards for cities and regions in Germany (e.g., “Bulletin board Hamburg” (Schwarzes Brett Hamburg)). Further, the link to the online survey was promoted in LGBTQIA* community support groups like the FacebookTM group “Queer in Germany (LGBTQ+)” (Queer in Deutschland (LGBTQ+)). Moreover, the questionnaire was distributed within several networks of LGBTQIA* communities like the “Lesbian and Gay Federation in Germany” (Lesben- und Schwulenverband–LSVD), the largest German non-governmental LGBT rights organization. Additionally, we promoted the survey through email distribution lists of Ludwig Maximilian University of Munich. Some participants promoted the survey within their own networks (snowball sampling). Prior to data collection, all participants reviewed and accepted an online-based consent page which included information on the research project. Participation in the study was anonymous, voluntarily and without any compensation. The survey was registered by the Ethics Review Committee of the Faculty of Medicine, LMU Munich (registration number: 20-344KB) and conducted with accordance of the Declaration of Helsinki. A total of N = 2463 participants participated in the online survey. To maximize participation, the inclusion criteria were held broad and included only (1) a minimum age of 18 years and (2) German proficiency. Due to missing values, n = 131 participants had to be excluded from the analysis. Therefore, eligible participants for analysis resulted in N = 2332 participants.

Measures

Gender identity and sexual orientation

Gender identity and sexual orientation were assessed with the item “In your opinion, which of the following categories most apply to you?”. The following answer categories were provided: heterosexual, homosexual, bisexual, asexual, female, male, cis (“I identify with the gender assigned at birth”), trans* (“I do not identify with the gender assigned at birth”) and others. Note that we are aware of the pathologizing nature of the term “homosexual”. In Germany, the term “homosexuell” is still widely used; for reasons of transparency, we report the direct translation as it appeared in the survey question. Multiple answers were possible. For the purpose of the analysis, we divided all participants into 12 groups according to their self-assigned gender identity and sexual orientation: (I) cis-heterosexual women, (II) cis-heterosexual men, (III) cis-lesbian women, (IV) cis-gay men, (V) cis-bisexual women, (VI) cis-bisexual men, (VII) cis-asexual women, (VIII) cis-asexual men, (IX) trans* women, (X) trans* men, (XI) non-binary gender identities (participants who identify as female and male), and (XII) inter* people. The star (*) indicates that the respective terms include further gender identities beyond the expression transgender, transident, transsexual and inter*, respectively. Regardless of their sexual orientation, all participants who reported a minoritized gender identity to their form one analytical group separate from cis-gendered people with minoritized sexual identities in the presented descriptive statistics and the analyses. The three analytical groups are: individuals with minoritized sexual identities (cis-lesbian women, cis-gay men, cis-bisexual women, cis-bisexual men, cis-asexual women and cis-asexual men), individuals with minoritized gender identities (trans* women, trans* men, non-binary gender and inter* people) and cis-heterosexual individuals (cis-heterosexual women and cis-heterosexual men). For the multivariate analysis we used dichotomous variables for cis-lesbian/gay, cis-bisexual, cis-asexual, trans*, non-binary and inter* individuals whereby cis-heterosexual served as the reference group in each of these variables.

Well-being

We used the 5-item short version of World Health Organization-Five Well-Being Index-10 (WHO-5) to measure current mental well-being [41]. The WHO-5 is a brief self-reported questionnaire, which consists of five items assessing subjective psychological well-being over a 14-day period. Each item is scored from 0 (none of the time) to 5 (all of the time). The total raw score ranges from 0 to 25, whereby higher values indicate better well-being. A total raw score ≤ 13 indicates a clinically significant depression [6]. The final score is calculated multiplying the total raw score by 4, with 0 representing the worst imaginable well-being and 100 representing the best imaginable well-being. This was conducted in order to compare the values with data from the German validation study of the WHO-5 [42]. In the present study, the scale showed very good internal consistency (Cronbach’s alpha  =  0.873).

Protective factors for well-being

Items were treated as categorical variables. For more details, see descriptive statistics in Table 1. In the multivariate analysis we used the following dichotomous variables: age (under 35 years versus 36 years and above), employment status (employed versus not employed (including students)), residential environment (urban cities versus rural communities under 20,000 inhabitants), relationship status (single versus in a relationship), parenthood (yes/no), and COVID-19 status (current or previous COVID-19 infection versus not infected or not tested).

Table 1

Descriptive statistics of the sample; n (%).

	Cis-heterosexual individuals		Cis-individuals with minoritized sexual identities						Individuals with minoritized gender identities
N = 2332	Women	Men	Lesbian women	Gay men	Bisexual women	Bisexual men	Asexual women	Asexual men	Trans* women	Trans* men	Non-binary	Inter*
	n = 1 004	n = 300	n = 353	n = 108	n = 254	n = 80	n = 29	n = 7	n = 60	n = 96	n = 31	n = 10
Age
18–25 years	389 (38,8)	123 (41.0)	90 (25.5)	18 (16.7)	95 (37.4)	25 (31.3)	14 (48.3)	3 (42.9)	12 (20.0)	27 (28.1)	9 (30.0)	6 (60.0)
26–35 years	476 (47.5)	118 (39.9)	141 (39.9)	50 (46.3)	102 (40.2)	24 (30.0)	12 (41.4)	2 (28.6)	34 (56.7)	30 (31.3)	11(36.7)	1 (10.0)
36–45 years	116 (11.6)	35 (11.7)	93 (26.3)	19 (17.6)	46 (18.1)	26 (32.5)	0 (0.0)	2 (28.6)	12 (20.0)	36 (37.5)	8 (26.7)	0 (0.0)
Over 46 years	21 (2.1)	24 (8.0)	29 (8.2)	21 (19.4)	11 (4.3)	5 (6.3)	3 (10.3)	0 (0.0)	2 (3.3)	3 (3.1)	2 (6.7)	3 (30.0)
Relationship status
Single	267 (26.6)	102 (34.0)	81 (22.9)	33 (30.6)	100 (39.4)	43 (53.8)	19 (65.5)	6 (85.7)	28 (46.7)	58 (60.4)	16 (51.6)	8 (80.0)
In a relationship	737 (73.4)	198 (66.0)	272 (77.1)	75 (69.4)	154 (60.6)	37 (46.3)	10 (34.5)	1 (14.3)	32 (53.3)	38 (39.6)	15 (48.4)	2 (20.0)
Parenthood
yes	823 (87.6)	223 (82.0)	250 (77.2)	87 (87.0)	202 (84.2)	44 (62.0)	24 (85.7)	5 (100.0)	52 (86.7)	82 (88.2)	21 (84.0)	6 (75.0)
no	117 (12.4)	49 (18.0)	74 (22.8)	13 (13.0)	38 (15.8)	27 (38.0)	4 (14.3)	0 (0.0)	8 (13.3)	11 (11.8)	4 (16.0)	2 (25.0)
Residential environment
Metropolis1	674 (67.3)	184 (61.3)	178 (50.6)	67 (62.0)	153 (60.5)	58 (72.5)	18 (62.1)	6 (85.7)	46 (76.7)	59 (61.5)	25 (80.6)	8 (80.0)
Medium-sized town2	131 (13.1)	46 (15.3)	73 (20.7)	12 (11.1)	34 (13.4)	7 (8.8)	6 (20.7)	0 (0.0)	10 (16.7)	12 (12.5)	4 (12.9)	0 (0.0)
Small town3	107 (10.7)	40 (13.3)	44 (12.5)	23 (21.3)	31 (12.3)	10 (12.5)	3(10.3)	0 (0.0)	21 (21.9)	2 (6.5)	1 (10.0)	1 (10.0)
Rural community4	90 (9.0)	30 (10.0)	57 (16.2)	6 (5.6)	35 (13.8)	5 (6.3)	2 (6.9)	1 (14.3)	1 (1.7)	4 (4.2)	0 (0.0)	1 (10.0)
Employment status
Self-employed	53 (5.3)	11 (3.7)	23 (6.5)	6 (5.6)	14 (5.5)	4 (5.0)	5 (17.2)	0 (0.0)	4 (6.7)	5 (5.3)	2 (6.5)	0 (0.0)
Employed	464 (46.3)	135 (45.2)	244 (69.3)	80 (74.8)	135 (53.1)	49 (61.3)	8 (27.6)	3 (42.9)	38 (63.3)	52 (54.7)	17 (54.8)	2 (20.0)
Student	425 (42.4)	136 (45.5)	59 (16.8)	18 (16.8)	82 (32.3)	23 (28.7)	14 (48.3)	4 (57.1)	7 (11.7)	18 (18.9)	7 (22.6)	7 (70.0)
Not employed	60 (6.0)	17 (5.7)	26 (7.4)	3 (2.8)	23 (9.1)	4 (5.0)	2 (6.9)	0 (0.0)	11 (18.3)	20 (21.1)	5 (16.1)	1 (10.0)
COVID-19 status
Infected, symptoms	0 (0.0)	2 (0.7)	0 (0.0)	1 (1.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Infected, no symptoms	2 (0.2)	0 (0.0)	1 (0.3)	1 (1.0)	0 (0.0)	1 (1.3)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Previous infected	7 (0.7)	2 (0.7)	2 (0.6)	0 (0.0)	0 (0.0)	1 (1.3)	0 (0.0)	1 (16.7)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Not infected/not tested	983 (99.1)	294 (98.7)	337 (99.1)	101 (98.1)	250 (100)	74 (97.4)	29 (100)	5 (83.3)	58 (100)	96 (100)	30 (100)	10 (100)

Notes: 1 = 100,000 or more inhabitants,

2 = 20,000 to 100,000 inhabitants,

3 = 5,000 to 20,000 inhabitants,

4 = up to 5,000 inhabitants.

Statistical analyses

This study focuses on the impact of the COVID-19 precautionary measures on well-being in individuals with minoritized sexual and gender identities compared to cis-heterosexual individuals. First, descriptive statistics were calculated for all subgroups and variables of interest (Table 1). To explore Hypothesis 1, assuming that individual’s current overall levels of well-being in Germany have decreased during the COVID-19 pandemic compared to prior levels before the COVID-19 pandemic, t-tests against a fixed value from a previous study [42] were conducted. To test Hypothesis 2, saying that individual’s current overall levels of well-being are lower among LGBTQIA* populations compared to a cis-heterosexual population, we conducted a two-sample t-test for the comparison of the groups cis-heterosexual vs. not cis-heterosexual as well as an ANOVA with post-hoc tests for more differentiated insights. To analyze which group has a higher probability of being below the WHO-5 cut-off score, we performed a logistic regression. To answer the Research Question, we examined the association between subgroups and current well-being by conducting a multivariate linear regression. We used the WHO-5 final score as our dependent variable, and the dummy variables of the individual identities (cis-heterosexual as reference versus cis-lesbian/gay, cis-bisexual, cis-asexual, trans*, non-binary and inter*) as independent variables. Further, we included the following protective factors for well-being in the model: age, residential environment, employment status, relationship status, parenthood and COVID-19 status. Hayes’ PROCESS tool (model 1) was used for moderation analyses to test the influence of potentially protective factors. A significance level of 0.05 was set for all analyses. We used SPSS (Version 26) and RStudio (Version 1.4.1106) for statistical analysis.

Results

In total, N = 2332 participants were included in the analysis. Of those, n = 1304 (55.9%) self-identified as cis-heterosexual individuals, n = 832 (35.6%) self-identified as individuals with minoritized sexual identities, and n = 197 (8.4%) self-identified as individuals with minoritized gender identities. Among the cis-gender respondents, there were more women (n = 1640, 76.8%) than men (n = 495, 23.2%). Concerning age, the vast majority of individuals with minoritized sexual identities, individuals with minoritized gender identities and cis-heterosexual individuals were younger than 36 years old. In terms of employment status most of the participants across all three groups n = 1354 (58.1%) were currently working and a total of n = 800 (34.3%) participants were students. Regarding the residential environment, most participants n = 1811 (77.7%) lived in urban cities with more than 20,000 inhabitants. Only n = 8 participants reported a current COVID-19 infection and n = 13 reported a previous COVID-19 infection. For more details on each individual group, descriptive statistics of the sample can be obtained from Table 1.

To test Hypothesis 1, the mean value of well-being M = 75.6 (SD = 13.85) from the study by Brähler et al. [42] was used as a fixed value. Results have shown that levels of well-being in all groups were significantly lower compared to the mean score from the reference sample by Brähler and colleagues. However, it is important to note that the standard deviations of the current study were higher than in the reference survey sample (for more detail see Table 2).

Table 2

Means, standard deviations and ranges for the WHO-5 across individuals and subgroups.

Group	N	M1	SD2	Range3	Cut-off7n (%)	t(df)8	p-value8	d9
Individuals
Cis-heterosexual	1 304	54.90	20.20	0–100	586 (44.9)	-37.02 (1303)	< 0.001	1.20
Women	1 004	55.02	20.02	0–100	447 (44.5)
Men	300	54.50	20.82	0–100	139 (46.3)
Cis-lesbian/gay	461	54.08	20.70	0–100	200 (43.4)	-22.32 (460)	< 0.001	1.22
Women	353	53.81	20.39	4–96	158 (44.8)
Men	108	54.96	21.74	0–100	42 (38.9)
Cis-bisexual	334	47.95	20.86	0–100	208 (62.3)	-24.22 (333)	< 0.001	1.56
Women	254	49.31	20.87	0–100	151 (59.4)
Men	80	43.65	20.38	0–88	57 (71.3)
Cis-asexual	36	47.00	23.39	4–96	20 (55.6)	-7.34 (35)	< 0.001	1.49
Women	29	42.35	21.42	4–80	18 (61.1)
Men	7	66.29	22.61	40–96	2 (28.6)
Trans*	156	49.00	23.89	4–92	84 (53.8)	-13.91 (155)	< 0.001	1.36
Women	60	50.08	23.66	12–92	29 (48.3)
Men	96	47.88	24.09	4–84	55 (57.3)
Non-binary	31	48.26	23.19	16–80	17 (54.8)	-6.57 (30)	< 0.001	1.43
Inter*	10	64.00	13.60	44–76	4 (40.0)	-2.70 (9)	0.024	0.85
Total sample/Subgroups
Total sample	2 332	53.18	20.90	0–100	1 119 (48.0)	-51.81 (2331)	< 0.001	1.37
Minoritized sexual identities	831	51.29	21.09	0–100	428 (51.5)	-33.20 (830)	< 0.001	1.36
Minoritized gender identities	197	49.64	23.52	4–92	105 (53.3)	-15,48 (196)	< 0.001	1.35

Notes: 1 = mean of the well-being final score,

2 = standard deviation of the well-being final score,

3 = range of the well-being final score,

7 = total raw score ≤ 13 indicates a clinically significant depression,

8 one sample t-tests against the value M = 75.6 (mean well-being final score in the reference sample from Brähler et al. (2007)). Please note that the sample of Brähler et al. consisted of mainly cis-heterosexual individuals.

9 = Cohen’s d.

To test Hypothesis 2, a two sample t-test revealed that participants within the cis-heterosexual group had a significant higher mean level of well-being (M = 54.90, SD = 20.20) compared to participants who assigned themselves to the overall LGBTQIA* group (M = 51.31, SD = 21.09), t(1711.40) = 3.89, p = < 0.001, d = 0.17. ANOVA results showed a significant group effect, F(6,2325) = 7.51, p < 0.001 indicating differences in well-being between the subgroups within the LGBTQIA* group. Post-hoc tests were calculated to determine which groups differ significantly in well-being from the cis-heterosexual group. Results revealed that participants from the group cis-bisexual (p < 0.001), cis-asexual (p = 0.024) and trans* (p = 0.001) individuals showed significantly lower levels of well-being compared to participants from the cis-heterosexual group. In terms of clinically significant depression, descriptive analyses revealed that bisexual individuals reported the highest levels of clinical depression on the WHO-5, followed by cis-asexual individuals, non-binary individuals and trans* individuals. The lowest level of clinically significant depression was reported by cis-heterosexual individuals and cis-lesbian/gay individuals (for more detail see Table 2).

A chi-squared test indicated that the overall effect of the group is statistically significant (see Table 3). A logistic regression revealed that for cis-heterosexual individuals (reference), the log odds of being below the cut-off value (versus above) decrease significantly. However, for bisexual as well as for trans* individuals the log odds of being below the cut-off value (versus above) increase compared to the reference group. All other estimates were not significant. To answer the Research Question, a multivariate linear regression model (see Table 3) with the WHO-5 final score as the dependent variable revealed that there is a significant negative association between the level of well-being and minoritized sexual identities; in particular cis-asexual individuals, followed by cis-bisexual individuals. Minoritized gender identities, in particular non-binary and trans* individuals, were also negatively associated with well-being. Living in urban communities and being in a relationship were positively association with the level of well-being in this model. All other covariates had no significant effect.

Table 3

Logistic regression of self-assigned sexual and gender identities on clinically significant depression as dependent variable measured with WHO-5.

	Chi2 (df)	Regression coefficient	Standard Error	Odds Ratio	p-value	95%-confidence interval
						Lower	Upper
Group	39.90 (6)				< 0.001
Intercept (Cis-heterosexual as reference)		-0.20	0.06	0.81	< 0.001	0.73	0.91
Cis-lesbian/gay		-0.06	0.11	0.93	0.56	0.75	1.16
Cis-bisexual		0.70	0.13	2.02	< 0.001	1.58	2.59
Cis-asexual		0.42	0.34	1.53	0.21	0.78	3.02
Trans*		0.35	0.17	1.42	0.04	1.02	1.99
Non-binary		0.39	0.37	1.48	0.28	0.72	3.09
Inter*		-0.20	0.65	0.81	0.75	0.20	2.87

Note: 1 = 5-item short version of World Health Organization-Five Well-Being Index-10.

Since the multivariate linear regression analysis showed that the variables relationship status and residential environment have a significant influence on well-being, we explored in a next step whether these variables influence the effect of individual identity on well-being. To test whether relationship status influences the association between minoritized sexual and gender identities (cis-heterosexual vs. LGBTQIA*) and well-being, a moderation analysis was conducted. Results showed a significant positive interaction effect of LGBTQIA* identities and relationship status (see Table 4). Substantively this means, as revealed by the conditional effects, that LGBTQIA* individuals without a partner have particularly low well-being, whereas the gap to cis-heterosexual individuals is narrower for LGBTQIA* individuals with a partner. In other words, the results indicate that the negative association between well-being and LGBTQIA* identities is mitigated by being in a relationship but not erased completely. A further analysis concerning the residential environment showed no moderator effect (see Table 4).

Table 4

Linear regression model with WHO-5 final score as dependent variable and moderation analyses.

	Regression coefficient	Standardized coefficient	Standard error	p-value	95%-confidence interval
					Lower	Upper
Intercept	47.95		10.30	< 0.001	27.76	68.14
Individual identities
- Cis-heterosexual (reference)	-		-	-	-	-
- Cis-lesbian/gay	-0.67	-0.01	1.22	0.59	-3.04	1.73
- Cis-bisexual	-6.90	-0.12	1.34	< 0.001	-9.51	-4.26
- Cis-asexual	-8.80	-0.05	3.66	0.02	-15.98	-1.62
- Trans*	-4.56	-0.06	1.82	0.01	-8.12	-0.10
- Non-binary	-9.73	-0.05	4.36	0.03	-18.27	-1.19
- Inter*	11.85	0,04	7.35	0.10	-2.56	26.26
Agea	-0.77	-0.02	1.19	0.51	-3.09	1.55
Relationship statusb	3.02	0.07	0.99	< 0.001	1.07	4.97
Employment statusc	-1.50	-0.04	1.12	0.18	-3.69	0.68
Residential enviromentd	-1.92	-0.04	0.96	0.046	-3.79	-0.04
Parenthoode	-2.21	-0.00	1.30	0.09	-4.76	0.34
Covid-19 statusf	5.31	0.24	4.76	0.27	-4.03	14.65
Statistics for linear regression
R2	0.03
Adjusted R2	0.03
Standard Error	20.62
F-statistic	5.60**
Moderation Analysesg
Identityh* Relationship statusb	3.98	0.20	1.95	0.04	0.15		7.81
Identityh without a partner	-6.05	-0.13	1.09	< 0.001	-9.22		-2.89
Identityh in a relationship	-2.07	-0.05	1.09	0.06	-4.22		0.08
Identityh*Residential enviromentd	0.91	0.04	0.18	0.63	-2.76		4.60

Notes: a. 1 = under 35 years; 2 = 36 years and above;

b. 1 = single, 2 = in a relationship;

c. 1 = employed, 2 = not employed including students;

d. 1 = urban cities, 2 = rural communities under 20.000 inhabitants;

e. 1 = no children, 2 = one or more children;

f. 1 = current or previous COVID-19 infection, 2 = not infected or not tested;

g. using Hayes’ PROCSS tool (model 1);

h. 1 = cis-heterosexual individuals, 2 = individuals with minoritized sexual and/or gender (LGBTQIA*) identities.

Discussion

The present study provides unique evidence on the comparison of well-being among cis-heterosexual individuals and LGBTQIA* individuals during the COVID-19 pandemic. Based on previous literature, we hypothesized overall lower levels of well-being in all individuals during the COVID-19 pandemic compared to levels prior to the COVID-19 pandemic (based on prior empirical work; Hypothesis 1); as well as lower levels of well-being among individuals with minoritized gender and/or sexual identities compared to cis-heterosexual individuals (Hypothesis 2). Further, the influence of age, residential environment, employment status, relationship status, parenthood and COVID-19 status in the association between well-being and sexual and gender identities was explored (Research Question).

First, overall results of the present study confirmed lower levels of well-being in all groups during the COVID-19 pandemic. Comparing these results with data obtained during the validation of the German version of the WHO-5 prior to the COVID-19 pandemic, we found a significant lower overall mean of the well-being score [42]. This finding is in line with our Hypothesis 1 as lower levels of well-being were expected during the current COVID-19 pandemic. A recently published empirical study reporting on mental health during the COVID-19 pandemic in Germany has similarly found an overall decrease in well-being measured with the WHO-5 [43]. In light of staggering preexisting mental health gradients between LGBTQIA* and cis-heterosexual people in Germany–documented just prior to the pandemic [21]–the findings of the current study are alarming.

Second, when comparing well-being levels among all individuals with minoritized gender and sexual identities with cis-heterosexual individuals, results indicated higher levels of well-being among cis-heterosexual individuals compared to LGBTQIA* people. The results were mainly driven by the group of cis-bisexual, cis-asexual and trans* individuals, which showed significant lower levels in well-being compared to participants from the cis-heterosexual group. The finding concerning LGBTQIA* individuals as one group was expected (Hypothesis 2) and is in line with previous empirical work [21]. Research in this field is growing, and the vast majority of studies report significantly poorer well-being and mental health in individuals with minoritized sexual and/or gender identities when compared with heterosexual and cisgender individuals [44-47]. A recent systematic literature review of N = 77 studies reported higher general distress, depressive symptoms, anxiety, suicidality as well as exposure to trauma and substance abuse among LGBTQIA* individuals [20]. Further, in line with the Minority Stress Model [24,25], EU-LQBTI surveys reported high levels of discrimination in access to and experience with healthcare [48,49]. LGBTQIA* individuals experience numerous health disparities and poor mental health, especially in times of the COVID-19 pandemic [50]. Another study where mental health of LGBT college students from the U.S. during the COVID-19 pandemic was examined, reported that approximately 60% of the sample were experiencing psychological distress, anxiety, and depression during the pandemic [34].

Our analyses further showed well-being heterogeneity within the LGBTQIA* group. With regard to sexual identity among cis-individuals, results suggest asexual and bisexual individuals at particular risk for poor mental health. In addition, the results show that the likelihood of being below the cut-off value for clinically significant depression was significantly increased in bisexual individuals and significantly decreased in heterosexual individuals. This finding is in line with previous empirical work [51-53]. For example, in a systematic review and meta-analysis on the prevalence of depression and anxiety, higher rates of depression and anxiety were consistently reported among bisexual individuals compared to heterosexual individuals and higher or equivalent rates in comparison to lesbian/gay individuals [54].

Notably, we did not find a significant difference between cis-lesbian/gay and cis-heterosexual individuals in regards to clinically significant depression in our data, nor does the effect suggest any sizable difference in means. Existing literature would suggest that lesbian women and gay men have poorer mental health than heterosexual individuals. In light of the mounting evidence that such a well-being gap exists, self-selection into the current study may play a role; specifically, particularly well-adjusted cis-lesbian women and cis-gay men or cis-heterosexual people with particularly poor mental health who dampen the group difference in well-being. Indeed, the sample is made up of many cis-women, whose consistently higher levels of depression than men are well-documented [55]. The sample further contains a noticeably large share of cis-lesbian and cis-gay individuals who are in relationships; also possibly a by-product of the family planning topic. As we have illustrated in this study, having a partner is a factor that minimizes the adverse well-being outcomes, which is another reason that likely led us to underestimate the well-being gap between cis-lesbian/gay individuals compared to cis-heterosexual individuals. In other words, the overall difference we found in this study between cis-heterosexual and LGBTQI* individuals is likely even more pronounced in general populations with adequate representation of cis men in general and unpartnered cis-gay/lesbian identifying individuals.

Regarding the analyses of individuals with minoritized gender identities, heightened rates of clinical depression among trans* and non-binary people were found in the regression analyses. These findings mirror the existing literature on mental health disparities of trans* and gender non-conforming people. For example, a recent study confirmed that due to the COVID-19 pandemic, access to gender-affirming resources and the ability of transgender and non-binary people to live according to their preferred gender has been reduced [56]. While gender-affirming care has repeatedly been found to improve physical and mental health of people with minoritized gender identities [57,58], access to it was already difficult for many individuals. The COVID-19 pandemic created an additional burden. Negative impacts of the pandemic include deferrals of and limited access to gender-affirming treatment (e.g., hormonal treatment, surgery), services (e.g., hair removal, binders) as well as access to mental counseling and psychotherapy, which may be linked to increased depressive symptoms [56]. Further, similar to our results, the same study reported about half of the participants screened positive for clinically significant depression.

With regard to protective factors for well-being, results revealed that being in a partnership and living in urban areas are relevant for well-being for all individuals in general, and particularly so for LGBTQIA* individuals. Interestingly, these significant protective factors for well-being, can also be interpreted as protective factors within the Minority Stress Model [20,25]. The protective role of being in a romantic partnership has already been reported in the past [35,37]. Further, previous literature has acknowledged social support [59-61] and in particular romantic relationships [58,62], to be associated with higher levels of wellbeing and mental health among individuals with minoritized gender and sexual. In addition, results of the present study indicate the negative association between LGBTQIA* identities and well-being is mitigated by being in a relationship. Future research should focus more closely on examining the buffering role of romantic relationships in the association between individuals with minoritized gender and sexual identities and well-being. With regard to living in urban areas, past research has repeatedly found that individuals of LGBTQIA* communities from rural areas experience high negative mental health consequences of minority stress [63]. Further, rural residents in general, but especially individuals from LGBTQIA* communities, report barriers and difficulties in the access of mental healthcare, among others because mental health services are in short supply [64]. The current COVID-19 pandemic and its restrictions represent an additional burden to healthcare access, especially for LGBTQIA* communities.

To sum up, results of the present study underline the particular vulnerability of LGBTQIA* individuals during the COVID-19 pandemic. In order to improve well-being and mental health among this group, access to mental healthcare should be strengthened during the COVID-19 pandemic, especially in rural areas. Healthcare services with low barriers of access such as telehealth, online care programs, counseling and supervision, as well as training and psychoeducation through online platforms should be made readily available. Telehealth has been found to be effective and practically feasible for the provision of mental health service during this pandemic [65]. Another recent study concluded that telehealth not only constitutes an effective health service but also has the potential of rapid implementation in both metropolitan and rural areas. Thus, access to telehealth during pandemics should be facilitated, particularly to vulnerable communities at higher risk of poor mental health. Moreover, access to gender-affirming services should not be disrupted in this time but rather strengthened. This study has substantial strengths including the use of a large and nationwide sample with high participation rates of LGBTQIA* individuals. It is the first study of its kind which examined well-being among LGBTQIA* individuals compared to cis-heterosexual individuals during the COVID-19 pandemic. However, the following limitations exist. First, well-being was measured by self-report. Self-reports of mental health may differ from clinical diagnoses. For instance, Grobe et al. [66] found administrative diagnoses within the healthcare system showed higher rates compared with survey self-reported depressive symptoms. However, self-perceptions of mental health have their own right as they are related to mental components of subjective well-being. Future research should incorporate clinical diagnosis or administrative data of mental health problems in order to assess mental health more objectively. Secondly, in the current study, LGBTQIA* individuals–in particular cis-lesbian and cis-gay identifying individuals–who are in relationships are overrepresented. The detected differences in well-being are likely more pronounced in the general population of LGBTQI* people than the current study shows. Third, while this is the first study to examine well-being among LGBTQIA* individuals compared to cis-heterosexual individuals during the COVID-19 pandemic, data were obtained at a single time point. Therefore, no trends or within-person comparisons of mental health before and after the COVID-19 pandemic can be drawn. A larger number of observations of trans* and gender non-conforming individuals would allow for further distinction of this group, according to their sexual orientation, which may interact with minoritized gender identities in unique ways. Further, as the present study is a cross sectional study only, associations and not causations can be inferred from the data. Future research on well-being of individuals with minoritized sexual and gender identities during pandemics should focus on longitudinal research.

Conclusion

The present study’s findings reveal lower levels of well-being among all participants compared to research conducted before the COVID-19 pandemic. Levels of well-being were lower among individuals with minoritized sexual and gender identities compared to cis-heterosexual individuals. Further, results indicate a protective role of being in a partnership and living in an urban area. Access to mental healthcare and gender-affirming resources for LGBTQIA* individuals should be strengthened during the COVID-19 pandemic. Healthcare services with low barriers of access such as telehealth and online peer support groups should be made readily available, especially for vulnerable groups.

(SAV)

Click here for additional data file.

30 Mar 2021

PONE-D-21-06928

Well-being during COVID-19 pandemic: A comparison of individuals with minoritized sexual and gender identities and cis-heterosexual individuals

PLOS ONE

Dear Dr. Buspavanich,

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.

The two Reviewers made two conflicting judgments. In my opinion, I believe that the breadth of the sample collected and the correctness of the experimental design merit giving the authors a chance to respond to the Reviewers and revise the manuscript accordingly. I therefore urge the authors to resolve all comments from the two Reviewers. In particular, I urge the authors to pay particular attention to the issues raised by Reviewer 2 related to methodology (recruitment information) and proper interpretation of the data (e.g., between lesbian/gay and heterosexual individuals). Finally, I recall the importance of what Reviewer 1 raised regarding the use of a standard English language, which is a prerequisite for publication. I suggest that authors either state that the language review was conducted by a native English-speaking author or that they use a professional proofreading service.

Please submit your revised manuscript by May 14 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Stefano Federici, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

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

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following in the Competing Interests section:

'Pichit Buspavanich received a research grant from Gilead. All other authors have no conflict of interest to declare. Sven Mahner reports Research support, advisory board, honoraria and travel expenses from AbbVie, AstraZeneca, Clovis, Eisai, GlaxoSmithKline, Medac, MSD, Novartis, Olympus, PharmaMar, Pfizer, Roche, Sensor Kinesis, Teva, and Tesaro.'

a.Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests).  If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

b. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

4. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

Additional Editor Comments:

The two Reviewers made two conflicting judgments. In my opinion, I believe that the breadth of the sample collected and the correctness of the experimental design merit giving the authors a chance to respond to the Reviewers and revise the manuscript accordingly. I therefore urge the authors to resolve all comments from the two Reviewers. In particular, I urge the authors to pay particular attention to the issues raised by Reviewer 2 related to methodology (recruitment information) and proper interpretation of the data (e.g., between lesbian/gay and heterosexual individuals). Finally, I recall the importance of what Reviewer 1 raised regarding the use of a standard English language, which is a prerequisite for publication. I suggest that authors either state that the language review was conducted by a native English-speaking author or that they use a professional proofreading service.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript makes an incremental but important contribution to understanding mental health during the COVID pandemic. I have two suggestions for the authors. First, a short section on the research context would be useful to readers unfamiliar with Germany. For example, details on the German social safety net and how this may have offset some of the ill effects of the pandemic, such as unemployment, are things that may have a bearing on mental health status. If the German government had any responses to help mitigate the effects of the pandemic would also be relevant. Additionally, details on the legal and social climate toward gender and sexual minorities would be useful for understanding the mental health of this population. Such details about the local context could help show to what extent the results are generalizable in other locations. Second, the manuscript would benefit from a couple of rounds of careful editing. I noticed a number of grammatical errors and awkwardly worded passages that could use some cleaning up.

Reviewer #2: This manuscript addresses differences in well-being and depression between (1) sexual and gender minority individuals (SOGI) and their (2) cisgender heterosexual peers during the Covid-19 pandemic, using a German sample recruited from social media platforms. There are theoretical, methodological, and validity concerns that dampen enthusiasm for the manuscript.

The manuscript would benefit from stronger grounding in minority stress theory. This would allow the authors, for example, to remove stress from health outcomes (p.4), to distinguish between protective factors and covariates, and to specify hypotheses pertaining to protective factors. The authors imply that SOGI individuals will be more stressed by the pandemic and, thus, experience even poorer mental health than before the pandemic. This is not testable, given their data. The authors sometimes conflate findings and issues pertaining to gender minority individuals with those of sexual minority individuals, a problem apparent in the Introduction and Discussion.

The Method section would benefit from more recruitment information. As it reads, someone could not replicate the study. For examples, what chats were accessed on the social media sites and how was the study advertised to prospective participants. Such information may explain why the authors have more lesbians than gay men or bisexual women (Table 1). Data from representative samples of the population, at least in the US, indicate the opposite should have been found. This limitation needs to be addressed, given its validity implications. In addition, protective factors are not covariates and, thus, should be excised from such a listing. Address here the issue of raw and final scores that are mentioned in Table 2 and indicate which is used in analyses.

Be careful in the Discussion section. You indicate that all SOGI groups differed from heterosexual peers. However, the means between lesbian/gay and heterosexual individuals are often rather similar. When differences arise, so, too, do validity concerns that circle back to the sample. For example, fewer gay than heterosexual men meet cut-off for depression (38.9% vs. 46.3%). You indicate this finding is not significant. Nevertheless, the effect size seems noteworthy and it is contrary to expectations.

Issues Concerning the Tables:

1. Table 2 is confusing. It can be improved by focusing on the raw or final scores, as indicated above. Also, add the corresponding t-tests, p values, and d statistics for the last 2 rows, as it seems reasonable to compare the SOGI groups to Brähler’s data. I imagine most individuals in Brähler were heterosexual; please clarify in the table note. By “overall” sample, I gather you mean the analytic sample.

2. A table addressing Hypothesis 2 is necessary. It would provide the ANOVA test for well-being, the chi-square test for the depression cut-off, their effect sizes, and identify the significant pairwise comparisons.

3. For the current Table 3, please add the regression statistics for the significant moderating effects concerning the protective factors. Test moderating relations of sex by SOGI on outcomes.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Carina Heckert

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 May 2021

PONE-D-21-06928 Response to Reviewers

Editor Comments: The two Reviewers made two conflicting judgments. In my opinion, I believe that the breadth of the sample collected and the correctness of the experimental design merit giving the authors a chance to respond to the Reviewers and revise the manuscript accordingly. I therefore urge the authors to resolve all comments from the two Reviewers. In particular, I urge the authors to pay particular attention to the issues raised by Reviewer 2 related to methodology (recruitment information) and proper interpretation of the data (e.g., between lesbian/gay and heterosexual individuals). Finally, I recall the importance of what Reviewer 1 raised regarding the use of a standard English language, which is a prerequisite for publication. I suggest that authors either state that the language review was conducted by a native English-speaking author or that they use a professional proofreading service.

>>> Thank you very much for the opportunity to revise our manuscript. As suggested by the Editor, we have resolved all comments from the two Reviewers and in particular focused, as suggested by the Editor, on the revision of the Methodology (recruitment information) and the interpretation of the data. Further, we have asked a native English-speaking colleague to revise the language and added a statement in the acknowledgments. <<<

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

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

>>> We have addressed the requirements and made changes accordingly. <<<

2. Thank you for stating the following in the Competing Interests section:

'Pichit Buspavanich received a research grant from Gilead. All other authors have no conflict of interest to declare. Sven Mahner reports Research support, advisory board, honoraria and travel expenses from AbbVie, AstraZeneca, Clovis, Eisai, GlaxoSmithKline, Medac, MSD, Novartis, Olympus, PharmaMar, Pfizer, Roche, Sensor Kinesis, Teva, and Tesaro.'

a. Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

>>> Thank you very much for sharing your guide for authors. We confirm that our Competing Interest statement does not alter the adherence to PLOS ONE policies on sharing data and materials. Therefore, the Competing Interest statement will not need any change. With regard to data availability, we have agreed to share data without any restrictions. <<<

b. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

>>> As stated in the answer above, no change in the statement is necessary. <<<

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj. c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide.

>>> Many thanks for pointing out these important restrictions. We have agreed to share data without any restrictions. Thank you for updating the statement of Data Availability on our behalf. We have uploaded our data set. <<<

4. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

>>> Thank you for pointing out that the ethics statement should only appear in the Methods section. We have revised our manuscript accordingly. <<<

Reviewer #1: The manuscript makes an incremental but important contribution to understanding mental health during the COVID pandemic. I have two suggestions for the authors. First, a short section on the research context would be useful to readers unfamiliar with Germany. For example, details on the German social safety net and how this may have offset some of the ill effects of the pandemic, such as unemployment, are things that may have a bearing on mental health status. If the German government had any responses to help mitigate the effects of the pandemic would also be relevant. Additionally, details on the legal and social climate toward gender and sexual minorities would be useful for understanding the mental health of this population. Such details about the local context could help show to what extent the results are generalizable in other locations. Second, the manuscript would benefit from a couple of rounds of careful editing. I noticed a number of grammatical errors and awkwardly worded passages that could use some cleaning up.

>>> Thank you very much for these important comments. We agree that it is of great importance to provide information on the country specific research context, in order to ensure that readers will understand the German context. As suggested, we have added a section on the COVID-19 related research context in Germany with regard to social safety and health (page 4 of the manuscript). Further, as suggested, we have added details on the legal and social climate toward gender and sexual minorities in Germany (page 6 of the manuscript). Further, we have edited the entire manuscript and had it proofread by our dear colleague Grace O'Malley, PhD in Clinical Psychology, who is a native English speaker. <<<

Reviewer #2: The manuscript would benefit from stronger grounding in minority stress theory. This would allow the authors, for example, to remove stress from health outcomes (p.4), to distinguish between protective factors and covariates, and to specify hypotheses pertaining to protective factors. The authors imply that SOGI individuals will be more stressed by the pandemic and, thus, experience even poorer mental health than before the pandemic. This is not testable, given their data. The authors sometimes conflate findings and issues pertaining to gender minority individuals with those of sexual minority individuals, a problem apparent in the Introduction and Discussion.

>>> Thank you very much for this suggestion. We agree that the manuscript would benefit from a stronger grounding in Minority Stress Theory. Therefore, we have added considerably more details on the theory in the Introduction section (page 5 and 6 of the manuscript). However, please be aware that our research question was not to examine the influence of Minority Stress on well-being rather than a comparison of the levels of well-being among all LGBTQIA* populations compared to a cis-heterosexual population, Thus, in regards to the protective factors we would like to kindly explain, that the selected protective factors are indeed protective factors for well-being based on a literature review for variables such as age (Busch, Maske, Ryl, Schlack, & Hapke, 2013; Erhart & von Stillfried, 2012), employment (Busch et al., 2013), partnership status (Bulloch, Williams, Lavorato, & Patten, 2017; Gariepy, Honkaniemi, & Quesnel-Vallee, 2016), place of living (Rommel, Bretschneider, Kroll, Prütz, & Thom, 2017; Thom, Kuhnert, Born, & Hapke, 2017), and children (Gariepy et al., 2016) during the COVID-19 pandemic. In our opinion, this selection is more suitable for our study since we do a comparison of cis-heterosexual and non-cis/non-heterosexual individuals and therefore we aim to find protective factors which are associated in all groups. The Minority Stress Theory focusses only on protective factors pertaining to the unique stress experienced by people with minoritized sexual and gender identities. To make that clear, we replaced the term “Socio-demographic characteristics and other covariates” to “protective factors for well-being” in the Methods and Statistical analysis sections of the manuscript. To acknowledge the valuable point of the Reviewer #2, we added a sentence in the Discussion section (page 22 of the manuscript). Further, we carefully scanned the manuscript for any conflation of sexual and gender minority individuals. The analyses are structured in a way that shows LGBTQI* people both as one group and the heterogeneity within the LGBTQI* group. The latter point especially targets the problem that sexual and gender issues are so often conflated in this literature. We have adjusted the wording where appropriate throughout the introduction and discussion section to reemphasize that this distinction is intended and meaningful. <<<

Reviewer #2: The authors imply that SOGI individuals will be more stressed by the pandemic and, thus, experience even poorer mental health than before the pandemic. This is not testable, given their data. The authors sometimes conflate findings and issues pertaining to gender minority individuals with those of sexual minority individuals, a problem apparent in the Introduction and Discussion.

>>> Thank you very much for this important comment. We agree with Reviewer #2 and have therefore already included a statement in the limitation section in the first version of our manuscript (page 24 of the manuscript). In our opinion with this limitation readers are well informed about the caution of that matter. Further, as already mentioned above, we carefully scanned the manuscript to adjust any wording that may conflate findings in regards of sexual and gender minority individuals. Thank you for drawing attention to this important point. <<<

Reviewer #2: The Method section would benefit from more recruitment information. As it reads, someone could not replicate the study. For examples, what chats were accessed on the social media sites and how was the study advertised to prospective participants. Such information may explain why the authors have more lesbians than gay men or bisexual women (Table 1). Data from representative samples of the population, at least in the US, indicate the opposite should have been found. This limitation needs to be addressed, given its validity implications. In addition, protective factors are not covariates and, thus, should be excised from such a listing. Address here the issue of raw and final scores that are mentioned in Table 2 and indicate which is used in analyses.

>>> Thank you very much for addressing a lack of recruitment information. We agree that the recruitment description could benefit from more information. We have therefore added considerably more details regarding the recruitment (page 8 of the manuscript).

Relatedly, we have also addressed the limitation with regard to the high participation rate of cis-women, which we observe among those identifying as heterosexual and lesbian. This skewed recruitment is likely a by-product of the advertisement text used. We have included this caveat in the Method section. Implications for validity were added to the Discussion section (page 23 of the manuscript). With regard to the comment on protective factors, we have already addressed this in our comment above. With regard to the comment on raw and final scores, we followed Reviewer #2’s suggestions below and we decided to delete the rare score from Table 2 (see comments below) and changed Table 2 as suggested by Reviewer #2. <<<

Reviewer #2: Be careful in the Discussion section. You indicate that all SOGI groups differed from heterosexual peers. However, the means between lesbian/gay and heterosexual individuals are often rather similar. When differences arise, so, too, do validity concerns that circle back to the sample. For example, fewer gay than heterosexual men meet cut-off for depression (38.9% vs. 46.3%). You indicate this finding is not significant. Nevertheless, the effect size seems noteworthy and it is contrary to expectations.

>>> Thank you very much for this valuable point. We completely agree and would like to point out that we already discussed this matter in a paragraph in our first version of the manuscript (page 21 of the manuscript). However, to make this point clearer, we have now added another sentence in the manuscript (page 20 of the manuscript). <<<

Reviewer #2 Issues Concerning the Tables:

1. Table 2 is confusing. It can be improved by focusing on the raw or final scores, as indicated above. Also, add the corresponding t-tests, p values, and d statistics for the last 2 rows, as it seems reasonable to compare the SOGI groups to Brähler’s data. I imagine most individuals in Brähler were heterosexual; please clarify in the table note. By “overall” sample, I gather you mean the analytic sample.

>>> Thank you for these suggestions. As suggested, we have revised Table 2 (page 16 of the manuscript), deleted the finale scores and added t-tests, p-values and d statistics for the last two rows. Further, we added the table note. With “overall sample” we referred to the total sample of the present study, in order to differentiate between the overall sample and subgroups. However, to makes this clearer, we replaced “overall” with “total sample”. We believe Table 2 has benefited from these changes, many thanks for your suggestions. <<<

2. A table addressing Hypothesis 2 is necessary. It would provide the ANOVA test for well-being, the chi-square test for the depression cut-off, their effect sizes, and identify the significant pairwise comparisons.

>>> We thank Reviewer #2 for the suggestion to include another table with further analyses for testing Hypothesis 2 (Table 3, page 17 of the manuscript). However, since these are two different dependent variables (i.e., well-being and the dichotomous variable above/below cut-off score) we have found a compromise: The recommended ANOVA for well-being as well as posthoc tests are already reported in the text (see page 14). The mean values can be found in Table 2. In addition, as recommended by Reviewer #2, we now have conducted a chi-square test for the depression cut-off. The chi-square test showed a significant p-value (p < 0.001). To analyze which groups had a higher likelihood of being below the cut-off score, we performed logistic regression and included the results in a new table (Table 4, page 18 of the manuscript). <<<

3. For the current Table 3, please add the regression statistics for the significant moderating effects concerning the protective factors. Test moderating relations of sex by SOGI on outcomes.

>>> Thank you very much for this interesting point. As requested, we added Table 3 to include interaction results of the protective factors (page 17 of the manuscript). In addition, we have now included the moderation effect in the abstract. Further, we thank Reviewer #2 for the idea of testing sex as a moderator. In our opinion, in this cohort of individuals of minoritized gender identities, the variable sex must be analyzed with caution. In our study the variable sex was obtained in a self-assigned assessment. We used this information to assign into the different gender and sexual identities: (I) cis-heterosexual women, (II) cis-heterosexual men, (III) cis-lesbian women, (IV) cis-gay men, (V) cis-bisexual women, (VI) cis-bisexual men, (VII) cis-asexual women, (VIII) cis-asexual men, (IX) trans* women, (X) trans* men, (XI) non-binary gender identities (participants who identify as female and male), and (XII) inter* people. This information can be found under Measures in the Methods section. In our opinion, we would not gain more information with the moderation analysis of the identity and the sex. However, we performed this moderation analysis and revealed no significant effect for sex as moderator (p = 0.912), as expected. Therefore, we decided not to include this information in the revised manuscript as we believe it to be redundant. However, if the editor believes it is important to include this information, we are willing to present it. Please be aware that in this case the correct term would be “self-assigned gender”, which would also prevent any discrimination of the vulnerable group of minoritized gender identities. <<<

Submitted filename: PONE-D-21-06928_Response to Reviewers.docx

Click here for additional data file.

14 May 2021

Well-being during COVID-19 pandemic: A comparison of individuals with minoritized sexual and gender identities and cis-heterosexual individuals

PONE-D-21-06928R1

Dear Dr. Buspavanich,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Stefano Federici, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

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: The authors have addressed my previous concerns, which has led to significant improvement and clarity in the manuscript.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Carina Heckert

21 May 2021

PONE-D-21-06928R1

Well-being during COVID-19 pandemic: A comparison of individuals with minoritized sexual and gender identities and cis-heterosexual individuals

Dear Dr. Buspavanich:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Prof. Stefano Federici

Academic Editor

PLOS ONE