Disparities in behavioral health and experience of violence between cisgender and transgender Thai adolescents

Wit Wichaidit; Sawitri Assanangkornchai; Virasakdi Chongsuvivatwong

doi:10.1371/journal.pone.0252520

. 2021 May 28;16(5):e0252520. doi: 10.1371/journal.pone.0252520

Disparities in behavioral health and experience of violence between cisgender and transgender Thai adolescents

Wit Wichaidit ^1,^2,^*, Sawitri Assanangkornchai ^1,², Virasakdi Chongsuvivatwong ¹

Editor: Siyan Yi³

PMCID: PMC8162664 PMID: 34048495

Abstract

Background

The term "transgender" refers to an individual whose gender identity is different from their sex assigned at birth, whereas the term "cisgender" refers to an individual whose gender identity is the same as their sex assigned at birth. In Thailand, studies on health outcomes and quality of life of Thai transgender youths have not included assessments from nationally-representative samples. The objective of this study is to assess the extent that behavioral health outcomes and exposure to violence varied by gender among respondents of the National School Survey on Alcohol Consumption, Substance Use and Other Health-Risk Behaviors.

Methods

We used data from a nationally-representative self-administered survey of secondary school students in years 7, 9 and 11 and classified participants as cisgender boys, cisgender girls, transgender boys, and transgender girls. Participants also answered questions on depressive experience, suicidality, sexual behaviors, alcohol and tobacco use, drug use, and past-year experience of violence. We analyzed data using descriptive statistics and modified multivariate Poisson regression with adjustment for sampling weights to calculate adjusted prevalence ratios (APR) with 95% confidence intervals.

Results

A total of 31,898 respondents (82.8% of those who returned complete and valid questionnaires) answered questions on sex and gender identity and were included in the analyses (n = 31,898 respondents), approximately 2.5% of whom identified as transgender. Transgender boys had a higher prevalence suicidal ideation than cisgender boys (APR = 2.97; 95% CI = 1.89, 4.67) and cisgender girls (APR = 2.29; 95% CI = 1.55, 3.40). Transgender girls were less likely than cisgender boys and girls to be ever drinkers, while transgender boys were more likely than cisgender boys and girls to be ever drinkers. Transgender girls had higher past-year exposure to sexual violence than cisgender boys (APR = 2.74; 95% CI = 1.52, 4.95) and cisgender girls (APR = 4.93; 95% CI = 2.52, 9.67).

Conclusion

We found disparities in behavioral health and experience of violence between transgender and cisgender adolescents in Thailand. The findings highlighted the need for program managers and policy makers to consider expanding local efforts to address health gaps in the LGBTQ community to also include school-going youth population.

Introduction

Gender spectrum refers to the idea that gender can be seen as a fluid, multidimensional concept, where gender exists anywhere on a continuum that includes male and female [1]. Gender identity development refers to the development of the extent to which a person identifies oneself within the gender spectrum [2]. Gender identity gradually develops, starting from early childhood [2] and is complete around the time of puberty [3]. The term “cisgender” refers to an individual whose gender identity is the same as their sex assigned at birth. The term “transgender” refers to an individual whose gender identity is different from their sex assigned at birth.

Adolescence is also a precarious period when one is susceptible to behavioral health issues that can affect health outcomes in later life [4]. Behavioral health issues affect both transgender and cisgender adolescents, although a previous study has shown disparities in the prevalence of unsafe sexual practices, sexual violence, drug use, and depression [5]. Transgender people tend to have higher prevalence of high-risk behavior [6, 7], depression [8] and suicidality [8, 9].

Thailand is a middle-income country in South East Asia that experiences homonegativity, not unlike other countries in the region [10]. Although many perceive the country as a safe haven [11], Thai transgender women do report experiences of discrimination and violence [12]. Studies on health outcomes and quality of life of Thai transgender youths are either include only qualitative methods [13], or are mostly based on small-scale surveys without assessment of disparities between transgender and cisgender youths [14]. Moreover, previous studies tend to focus on male-to-female transgender youths, and scarce data exists on the health of female-to-male transgender youths.

The National School Survey on Alcohol Consumption, Substance Use and Other Health-Risk Behaviors was a nationally-representative large-scale cross-sectional study among Thai school-going adolescents that included questions on gender identity and behavioral health, presenting an opportunity to assess disparities by gender [15]. Secondary data from the survey are available for analysis. The 2016 survey was the third of its kind (the first two surveys were conducted in 2007 and 2009) and was the first survey in which the gender identity question was included in addition to the sex assigned at birth question. It is thus possible to assess disparities in behavioral health outcomes and experience of violence between Thai cisgender and transgender adolescents. Such information can provide evidence to inform school health programs regarding disparities in health problems and need and to plan and allocate resources for programmatic efforts to better support student health. The objective of this study is to assess the extent that behavioral health outcomes and exposure to violence varied by gender among respondents of the National School Survey on Alcohol Consumption, Substance Use and Other Health-Risk Behaviors.

Materials and methods

Study design and participants

The National School Survey on Alcohol Consumption, Substance Use and Other Health-Risk Behaviors (hence “Survey”) was a cross-sectional survey conducted to provide information about the magnitude and trend of alcohol consumption, tobacco use, substance use and other high-risk behaviors among Thai adolescents in Thailand’s formal educational system. The participants included students in Year 7 (Matthayom 1), Year 9 (Matthayom 3), and Year 11 in the general education system (Matthayom 5) and the vocational education system (Vocational Certificate Year 2). The survey covered public and private schools in urban and rural areas, and 40 out of 77 provinces of Thailand.

Instrumentation: Measurement of gender

We used the responses of two questions to define the genders in this study (Sub-Section A1: Sex): sex assigned at birth, and gender identity. The first question in Sub-Section A1 measured sex assigned at birth with the question “A1.1 Sex at Birth” with two possible answer choices: “1) Male”, and “2) Female”. The second question in Sub-Section A1 measured gender identity with the question “A1.2 Gender Identity (you think that your gender is…)” with two possible answer choices: “1) Male”, and “2) Female”.

Among the respondents, 0.9% did not answer A1.1 (sex assigned at birth) and 17.7% did not answer A1.2 (gender identity). We excluded participants who did not answer either one of these questions from the analysis. We therefore categorized students into 4 groups: 1) students who answered “Male” in A1.1 and “Male” in A1.2, labelled as “Cisgender Boys”; 2) students who answered “Female” in A1.1 and “Female” in A1.2, labelled as “Cisgender Girls”; 3) students who answered “Male” in A1.1 and “Female” in A1.2, labelled as “Transgender Girls”; 4) students who answered “Female” in A1.1 and “Male” in A1.2, labelled as “Transgender Boys” (Table 1).

Table 1. Gender classification definitions of respondents and proportions, weighted percent ± standard error (SE) (n = 31,898 respondents).

Group	Definition	Percent ± SE
1) Cisgender Boys (n = 14,040 respondents)	Respondents whose sex was "Male" and gender identity was "Male"	42.5% ± 1.3%
2) Cisgender Girls (n = 17,103 respondents)	Respondents whose sex was "Female" and gender identity was "Female"	55.0% ± 1.2%
3) Transgender Girls (n = 421 respondents)	Respondents whose sex was "Male" and gender identity was "Female"	1.4% ± 0.1%
4) Transgender Boys (n = 334 respondents)	Respondents whose sex was "Female" and gender identity was "Male"	1.1% ± 0.1%

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Instrumentation: Behavioral health

Behavioral health outcomes in this survey included depressive experience, suicidality, unsafe sexual behaviors, alcohol consumption, tobacco consumption, and drug use. Depressive experience referred to history of feeling of sadness or despair on a near-daily basis for a period of two weeks or more within the past 12 months. Suicidality-related questions included history of suicidal ideation, suicide planning, and suicide attempts within the past 12 months. Non-responses were treated as missing data.

Unsafe sexual behaviors included lifetime history of sexual intercourse, use of alcohol during last sexual encounter, use of illicit drugs during last sexual encounter, and use of contraception by respondent or partner during the last sexual encounter. We defined a lack of contraceptive use as reporting “None” or “Withdrawal (coitus interruptus)” as the method for contraception. Analyses of data related to sexual behaviors other than lifetime history were limited to only students who reported a lifetime history of sexual intercourse. We excluded students who did not answer the "have you ever had sex" question from the analyses.

For drinking and smoking behaviors, we considered students who reported ever drinking in their lifetime to be ever drinkers, and students who reported drinking in the past 12 months to be current drinkers. Similarly, we considered students who reported having smoked 100 cigarettes or more in their lifetime to be ever smokers, and students who reported smoking in the past 12 months to be current smokers. We excluded students who did not provide an answer on ever-drinking from the analyses on drinking, and we excluded students who did not provide an answer on ever-smoking from the analyses on smoking. We also assumed that students who never drank also had not consumed alcohol within the past 12 months, and that students who never smoked also had not smoked within the prior 12 months. The 12-month time frame for alcohol consumption was chosen to be consistent with the Tobacco and Alcohol Consumption Survey 2017 [16]. The 12-month time frame for tobacco use was chosen to be consistent with the definition used in the Global Adult Tobacco Survey (GATS) [17].

For drug use behaviors, we included drugs where the lifetime history of use was higher than one percent in the entire population: 1) marijuana; 2) kratom (Mitragyna speciosa); 3) methamphetamine pills, and; 4) crystal methamphetamine. The one percent cut-point was arbitrarily chosen in order to achieve adequate statistical power to make comparisons between cisgender and transgender youths. Non-responses were treated as missing data.

Instrumentation: Measurement of experience of violence

Exposure to violence was measured with questions on experience within the past 12 months of the survey regarding: 1) being threatened or assaulted with weapons; 2) being in a fight or quarrel; 3) intimate partner violence; 4) sexual violence. For intimate partner violence and sexual violence, we excluded students who never had an intimate partner and students who never had sex from the analyses, respectively. We also excluded non-responses from the analyses. We excluded participants who did not report any of the four types of violence from the calculation of exposure to any type of violence in the past 12 months.

Instrumentation: Demographic characteristics

The General Characteristics Section of the questionnaire contained information on school type, year level and track of study, religion, geographic region, living situation (participant’s accommodation arrangement), monthly allowance, and grade point average (GPA). We described variations regarding these characteristics by gender identities and included these as co-variables during multivariate analyses.

Procedure

The survey included data from schools in 40 out of 77 provinces. The survey researchers randomly selected half of the provinces in each of the 12 education regions (plus two districts in the capital of Bangkok), then sampled the schools. Survey researchers then contacted the school administrtors to ask for permission to conduct the Survey, and enumerators then visited the school, distributed the self-administered questionnaires to the students, explained about the Survey, and asked the students for verbal consent. The students then completed the questionnaires and placed the questionnaires in individual envelopes. The sampling method and data collection procedures have been described in detail elsewhere [15, 18].

Data analysis

We performed univariate analyses by describing the basic characteristics of the study respondents. We then performed bivariate analyses by cross-tabulation of gender classification of study respondents and the outcomes (behavioral health and exposure to violence). We then performed multivariate analyses to measure the association between gender classification and the outcomes adjusting for the effect of basic characteristics of the respondents using modified Poisson regression. The analyses were performed separately for each of the outcome variables. Our measure of association was the adjusted prevalence ratio with 95% confidence intervals (APR with 95% CI). In a similar manner to previous studies on health disparities among transgender people [19–21], we compared the prevalence of each outcome in each transgender group to the prevalence among cisgender boys and cisgender girls separately. We adjusted for the respondents’ personal characteristics including school type, year level, religion, geographic region, living situation, monthly allowance, and grade point average in the modified Poisson regression analyses, as was similarly done in a previous study [22]. We conducted all data analyses using R with the epicalc package [23] and the survey package [24] to generate weighted estimates and account for the complex study design.

Ethical considerations

The 2016 national school survey was approved by Khon Kaen University Ethical Review Board for Research in Human Subjects (EC: 59-396-18-1, Project Number HE581430). Ethical clearance for this secondary data analysis was granted exemption by the Ethics Committee for Research in Human Subjects of the Faculty of Medicine, Prince of Songkla University (Project number REC.62-054-18-1). A waiver of the need for a document of consent for minors was approved from the institutional review board. As anonymity was guaranteed and research procedures entailed no more than minimal risk to subjects, students were allowed to provide consent verbally in lieu of signing written informed consent forms.

Results

One percent (1%) of all students in the sampled classrooms refused to participate in the survey. Among students who agreed to participate (i.e., the respondents), fewer than five percent (5%) returned incomplete or potentially invalid questionnaires which were discarded. Out of 38,535 respondents who returned complete and valid questionnaires, 31,898 (82.8%) answered both questions on sex and gender identity and were included in the analyses (i.e., total sample size = 38,535 respondents; final analytic sample size = 31,898 respondents). Transgender girls and transgender boys accounted for approximately 2.5% of all respondents (Table 1). Respondents of all genders were similar to one another with regards to school type, religion, and geographic region (Table 2). However, transgender girls had higher mean monthly allowance than respondents of other genders, and a higher proportion of those in the highest GPA range (GPA = 3.1 to 4.0) than other genders except cisgender girls. Transgender boys had the highest proportion of respondents who lived in rented houses (either alone or with housemates) and the lowest proportion of respondents who lived in their family’s house/flat.

Table 2. Characteristics of study respondents, weighted percent ± SE unless otherwise noted (n = 31,898 respondents).

Characteristic	Cisgender boys (Percent ± SE)	Cisgender girls (Percent ± SE)	Transgender girls (Percent ± SE)	Transgender boys (Percent ± SE)	P-value^a
	(n = 14,040)	(n = 17,103)	(n = 421)	(n = 334)
School type
Government	66.7 ± 2.8	66.9 ± 3.1	73.7 ± 3.4	69.2 ± 8.1	0.725
Private	32.4 ± 2.8	32.0 ± 3.2	25.7 ± 3.4	29.8 ± 8.2
Unknown	1.0 ± 0.2	1.1 ± 0.4	0.5 ± 0.4	1.0 ± 0.8
Year Level
Mathayom 1 (Year 7)	29.0 ± 1.2	25.5 ± 1.0	12.6 ± 2.1	20.1 ± 2.3	<0.001
Mathayom 3 (Year 9)	27.3 ± 1.1	26.7 ± 0.8	29.4 ± 3.3	29.0 ± 3.9
Mathayom 5 (Year 11, General Education)	23.8 ± 1.1	36.0 ± 1.0	43.7 ± 3.8	29.4 ± 3.2
Vocational Certificate 2 (Year 11, Vocational Education)	20.0 ± 1.6	11.8 ± 0.9	14.3 ± 2.6	21.5 ± 2.7
Religion
Buddhism	90.6 ± 2.8	91.2 ± 2.5	86.9 ± 2.8	92.0 ± 2.2	0.602
Islam	7.1 ± 2.9	6.5 ± 2.7	8.3 ± 2.6	5.3 ± 2.1
Christianity	2.1 ± 0.4	2.2 ± 0.5	4.5 ± 1.6	2.6 ± 0.9
Others	0.2 ± 0.0	0.1 ± 0.1	0.3 ± 0.3	0.1 ± 0.1
Region
Special-Bangkok	7.8 ± 7.4	10.8 ± 9.9	13.7 ± 12.2	16.5 ± 14.2	0.071
Bangkok Metro Areas	4.4 ± 3.2	3.7 ± 2.7	4.2 ± 3.0	3.9 ± 3.0
Central	22.0 ± 7.4	21.4 ± 7.9	15.6 ± 6.0	19.8 ± 7.6
South	14.2 ± 6.3	13.3 ± 5.7	7.8 ± 3.5	12.4 ± 6.0
North	22.7 ± 7.6	23.4 ± 8.2	22.8 ± 9.1	22.0 ± 8.8
Northeast	28.9 ± 8.6	27.4 ± 8.7	36.0 ± 11.1	25.5 ± 9.0
Living Situation
Family house/flat	85.1 ± 1.9	85.3 ± 1.6	80.6 ± 3.2	77.7 ± 2.7	0.019
School dorm	4.2 ± 2.0	3.3 ± 1.3	4.1 ± 2.0	2.5 ± 1.1
Outside dorm	3.2 ± 0.5	2.8 ± 0.5	5.5 ± 1.4	6.5 ± 2.1
Rented house	6.6 ± 1.0	7.4 ± 1.4	8.2 ± 3.3	11.1 ± 2.3
Others (relatives, temple)	1.0 ± 0.2	1.2 ± 0.3	1.6 ± 0.6	2.3 ± 1.1
Monthly allowance (THB) (mean ± standard errors)	2,544.1 ± 93.5	2,461.9 ± 110.4	3,533.4 ± 450.4	3,141.4 ± 440.4	<0.001^b
Grade point average (GPA)
GPA = 0.1–1.0	0.7 ± 0.2	0.2 ± 0.1	0.8 ± 0.4	0.0 ± 0.0	<0.001
GPA = 1.1–2.0	11.3 ± 0.9	3.6 ± 0.4	6.8 ± 1.5	5.2 ± 1.6
GPA = 2.1–3.0	44.2 ± 1.1	32.9 ± 1.4	38.6 ± 3.1	42.0 ± 3.0
GPA = 3.1–4.0	34.7 ± 1.9	56.8 ± 1.9	49.1 ± 2.7	42.6 ± 3.7
Unknown	9.0 ± 0.8	6.5 ± 0.8	4.7 ± 1.4	10.2 ± 2.3

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^aChi-square test of association with Rao & Scott adjustment, unless otherwise noted.

^bFrom results of one-way ANOVA with adjustment for complex survey design.

Transgender boys had higher prevalence of depressive experience and suicidality compared to cisgender boys and girls, particularly with regard to suicidal ideation in past 12 months (APR = 2.97; 95% CI = 1.89, 4.67 when compared to cisgender boys, and APR = 2.29; 95% CI = 1.55, 3.40 when compared to cisgender girls) (Table 3). Similarly, transgender girls had higher prevalence of suicidality compared to cisgender boys. Transgender respondents (both boys and girls) also had higher prevalence of foregoing contraceptive use at last sexual encounter compared to cisgender respondents (both boys and girls). Transgender girls were less likely than cisgender boys and girls to be ever drinkers, while transgender boys were more likely than cisgender boys and girls to be ever drinkers. Similar differences were also observed in prevalence of being ever smokers. Transgender boys had significantly higher prevalence of lifetime history of using illicit drugs compared to cisgender girls, particularly in the use of yaba (methamphetamine pills) (APR = 2.99; 95% CI = 1.33, 6.73).

Table 3. Prevalence (weighted percent ± SE) and adjusted prevalence ratios (APRs) of mental health outcomes and health behaviors among respondents, stratified by gender.

	Cisgender boys (Percent ± SE)	APR (95% CI)^a	Cisgender girls (Percent ± SE)	APR (95% CI)^a	Transgender girls (Percent ± SE)	APR (95% CI)^a (Ref. Cisgender boys)	APR (95% CI)^a (Ref. Cisgender girls)	Transgender boys (Percent ± SE)	APR (95% CI)^a (Ref. Cisgender boys)	APR (95% CI)^a (Ref. Cisgender girls)
	(n = 14,040)		(n = 17,103)		(n = 421)			(n = 334)
*Mental Health in past 12 months*
Depressive experience	(n = 13,004) 12.2% ± 0.6%	1.0 (Ref.)	(n = 16,346) 14.0% ± 0.8%	1.0 (Ref.)	(n = 399)19.1% ± 2.3%	1.31 (0.97, 1.76)	1.12 (0.82, 1.53)	(n = 313)22.6% ± 3.6%	1.78 (1.33, 2.40)	1.53 (1.15, 2.02)
Suicidal ideation	(n = 9,354) 5.8% ± 0.6%	1.0 (Ref.)	(n = 11,538)7.2% ± 0.7%	1.0 (Ref.)	(n = 290)11.5% ± 2.0%	1.66 (1.13, 2.45)	1.28 (0.89, 1.86)	(n = 239)16.0% ± 3.2%	2.97 (1.89, 4.67)	2.29 (1.55, 3.40)
Suicide planning	(n = 13,152)4.6% ± 0.3%	1.0 (Ref.)	(n = 16,487)5.7% ± 0.4%	1.0 (Ref.)	(n = 403)9.1% ± 1.7%	1.69 (1.09, 2.61)	1.27 (0.83, 1.94)	(n = 318)13.9% ± 2.4%	2.82 (1.74, 4.58)	2.13 (1.43, 3.17)
Suicide attempt	(n = 13,501)4.5% ± 0.6%	1.0 (Ref.)	(n = 16,742)5.1% ± 0.5%	1.0 (Ref.)	(n = 416)8.2% ± 2.0%	1.63 (1.07, 2.49)	1.33 (0.90, 1.98)	(n = 327)8.8% ± 1.9%	2.12 (1.17, 3.85)	1.73 (1.01, 2.97)
*Sexual Behaviors*
Ever had sex	(n = 13,618)17.3% ± 0.8%	1.0 (Ref.)	(n = 16,676)10.8% ± 0.8%	1.0 (Ref.)	(n = 417)21.8% ± 4.1%	1.09 (0.80, 1.47)	1.42 (1.04, 1.95)	(n = 326)15.7% ± 2.9%	0.88 (0.64, 1.21)	1.15 (0.83, 1.58)
*Among those who ever had sex*
Use of alcohol during last sexual encounter	(n = 2,265) 18.0% ± 1.0%	1.0 (Ref.)	(n = 1,776) 14.7% ± 1.4%	1.0 (Ref.)	(n = 76) 24.4% ± 5.4%	1.05 (0.60, 1.84)	1.36 (0.69, 2.68)	(n = 48) 14.7% ± 6.4%	0.75 (0.30, 1.85)	0.96 (0.44, 2.13)
Use of illicit drug during last sexual encounter	(n = 2,247) 6.9% ± 0.7%	1.0 (Ref.)	(n = 1,760) 3.3% ± 0.5%	1.0 (Ref.)	(n = 71) 5.9% ± 3.0%	0.41 (0.33, 0.60)	0.92 (0.26, 3.29)	(n = 48) 3.6% ± 2.6%	0.57 (0.12, 1.45)	1.28 (0.27, 6.00)
Foregoing contraceptive use during last sexual encounter	(n = 2,258) 28.2% ± 1.7%	1.0 (Ref.)	(n = 1,766) 25.6% ± 1.3%	1.0 (Ref.)	(n = 72) 47.2% ± 7.5%	1.96 (1.39, 2.76)	2.11 (1.59, 2.80)	(n = 49) 37.5% ± 8.5%	1.60 (1.05, 2.43)	1.72 (1.14, 2.61)
Condom use during last sexual encounter	(n = 2,258) 57.4% ± 1.8%	1.0 (Ref.)	(n = 1,766) 51.1% ± 1.5%	1.0 (Ref.)	(n = 72) 40.0% ± 8.3%	0.59 (0.33, 1.06)	0.68 (0.39, 1.17)	(n = 49) 19.1% ± 8.7%	0.34 (0.14, 0.81)	0.39 (0.16, 0.92)
*Alcohol and tobacco use*
Ever drinker	(n = 13,706)39.3% ± 1.1%	1.0 (Ref.)	(n = 16,786)35.6% ± 1.6%	1.0 (Ref.)	(n = 412)33.6% ± 2.7%	0.81 (0.70, 0.95)	0.85 (0.73, 1.00)	(n = 331)51.1% ± 5.2%	1.27 (1.06, 1.51)	1.33 (1.12, 1.59)
Drank in past 12 months (among ever drinkers)	(n = 5,162) 77.0% ± 1.2%	1.0 (Ref.)	(n = 5,686) 73.6% ± 1.0%	1.0 (Ref.)	(n = 136)79.1% ± 4.6%	1.01 (0.91, 1.11)	1.04 (0.94, 1.16)	(n = 163)75.1% ± 3.2%	0.97 (0.90, 1.05)	1.01 (0.93, 1.09)
Ever smoker	(n = 13,766)23.4% ± 1.8%	1.0 (Ref.)	(n = 16,743)6.1% ± 0.9%	1.0 (Ref.)	(n = 410)13.2% ± 3.1%	0.48 (0.34, 0.67)	1.46 (1.04, 2.05)	(n = 329)20.9% ± 4.2%	0.91 (0.66, 1.24)	2.77 (1.90, 4.03)
Smoked in past 12 months (among ever smokers)	(n = 3,523) 74.4% ± 1.6%	1.0 (Ref.)	(n = 1,120) 70.3% ± 2.4%	1.0 (Ref.)	(n = 52) 67.0% ± 4.6%	0.82 (0.60, 1.12)	0.85 (0.61, 1.18)	(n = 80) 56.9% ± 5.4%	0.74 (0.60, 0.91)	0.76 (0.61, 0.94)
*Lifetime history of illicit drug use*
Marijuana	(n = 10,746)8.1% ± 1.0%	1.0 (Ref.)	(n = 13,383)2.9% ± 0.4%	1.0 (Ref.)	(n = 284)6.2% ± 2.5%	0.56 (0.24, 1.30)	1.43 (0.63, 3.21)	(n = 261)8.9% ± 1.7%	1.01 (0.66, 1.55)	2.58 (1.80, 3.69)
Kratom	(n = 10,667)6.0% ± 1.0%	1.0 (Ref.)	(n = 13,382)2.2% ± 0.3%	1.0 (Ref.)	(n = 283)4.9% ± 2.2%	0.64 (0.30, 1.39)	1.44 (0.65, 3.17)	(n = 260)6.5% ± 1.3%	1.17 (0.83, 1.65)	2.61 (1.64, 4.16)
Yaba (methamphetamine pills)	(n = 10,673)2.9% ± 0.6%	1.0 (Ref.)	(n = 13,369)1.0% ± 0.3%	1.0 (Ref.)	(n = 279)0.7% ± 0.5%	0.10 (0.01, 1.07)	0.29 (0.03, 2.55)	(n = 261)3.4% ± 1.3%	1.07 (0.42, 2.73)	2.99 (1.33, 6.73)
Ice (crystal methamphetamine)	(n = 10,639)1.9% ± 0.4%	1.0 (Ref.)	(n = 13,360)1.0% ± 0.2%	1.0 (Ref.)	(n = 278)1.9% ± 0.8%	0.60 (0.15, 2.31)	1.17 (0.31, 4.40)	(n = 260)1.8% ± 0.8%	0.81 (0.29, 2.23)	1.58 (0.58, 4.30)

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^aAdjusted for school type, year level, religion, geographic region, living situation, monthly allowance, and grade point average. Bold texts denote statistically significant association.

Both transgender girls and transgender boys had higher exposure to violence in the past year than cisgender girls (Table 4), including being threatened, severe physical violence, and intimate partner violence. Transgender girls had higher past-year exposure to sexual violence than all other groups (APR = 2.74; 95% CI = 1.52, 4.95 compared to cisgender boys, and APR = 4.93; 95% CI = 2.52, 9.67 compared to cisgender girls).

Table 4. Prevalence (weighted percent ± SE) and adjusted odds ratios (AORs) of past-year exposure to violence among respondents of the TSSHRBS, stratified by gender.

	Cisgender boys (Percent ± SE)	APR (95% CI)^a	Cisgender girls (Percent ± SE)	APR (95% CI)^a	Transgender girls (Percent ± SE)	APR (95% CI)^a (Ref. Cisgender boys)	APR (95% CI)^a (Ref. Cisgender girls)	Transgender boys (Percent ± SE)	APR (95% CI)^a (Ref. Cisgender boys)	APR (95% CI)^a (Ref. Cisgender girls)
	(n = 14,040)		(n = 17,103)		(n = 421)			(n = 334)
*Past-year exposure to violence*
Being threatened	(n = 13,366)8.0% ± 0.6%	1.0 (Ref.)	(n = 16,611)2.0% ± 0.1%	1.0 (Ref.)	(n = 400) 6.7% ± 1.3%	0.66 (0.40, 1.09)	2.37 (1.48, 3.82)	(n = 317) 6.4% ± 2.1%	0.71 (0.43, 1.14)	2.52 (1.37, 4.65)
Severe physical violence	(n = 13,373)7.6% ± 0.5%	1.0 (Ref.)	(n = 16,613)2.5% ± 0.1%	1.0 (Ref.)	(n = 401) 7.9% ± 1.5%	0.91 (0.54, 1.52)	2.33 (1.48, 3.68)	(n = 318) 7.3% ± 2.0%	0.89 (0.62, 1.28)	2.29 (1.63, 3.23)
Intimate partner violence	(n = 13,192)7.3% ± 0.4%	1.0 (Ref.)	(n = 16,452)3.0% ± 0.3%	1.0 (Ref.)	(n = 397) 5.0% ± 1.2%	0.58 (0.34, 0.97)	1.16 (0.68, 1.98)	(n = 313) 10.8% ± 2.8%	1.33 (0.99, 1.78)	2.66 (2.09, 3.38)
Sexual violence	(n = 13,241)2.9% ± 0.2%	1.0 (Ref.)	(n = 16,531)1.3% ± 0.1%	1.0 (Ref.)	(n = 405) 9.4% ± 4.3%	2.74 (1.52, 4.95)	4.93 (2.52, 9.67)	(n = 319) 4.1% ± 1.2%	1.28 (0.74, 2.23)	2.31 (1.30, 4.12)
Experienced any type of violence in past 12 months	(n = 13,664)15.5% ± 0.9%	1.0 (Ref.)	(n = 16,843)6.4% ± 0.3%	1.0 (Ref.)	(n = 408) 18.6% ± 4.4%	1.04 (0.78, 1.38)	2.22 (1.68, 2.94)	(n = 330) 17.0% ± 2.9%	0.98 (0.71, 1.35)	2.09 (1.54, 2.83)

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^aAdjusted for school type, year level, religion, geographic region, living situation, monthly allowance, and grade point average. Bold texts denote statistically significant association.

Discussion

In a nationally-representative survey, we compared behavioral risk factors and past-year experience of violence between Thai transgender and cisgender secondary school students. We found significant disparities between transgender and cisgender youths. We found that transgender boys had the highest levels of depressive experience, suicidality, and history of alcohol consumption compared to other groups, while transgender girls had the highest prevalence of experiencing sexual violence within the year prior to the survey.

Parent or guardian permission was not a requirement for participation in this study, which might have improved the willingness of transgender youths to participate and identify themselves in the survey [25]. However, approximately one-sixth of the respondents did not answer the gender identity question. The Thai word in the questionnaire was ‘phet withi’, which was not part of vernacular Thai. It is possible that respondents who did not answer the gender identity question either did not understand it or perceived it to be a duplicate of the question pertaining to sex assigned at birth and decided to skip it. Future studies should consider changing the sex assigned at birth question may be changed from "Sex…" to "What sex were you assigned at birth?". Future studies should consider modification of the gender identity measurement question to help reduce this non-response, e.g., changing from "You think you are…" ("Khun kid waa khun ben phet…") to "What gender do you identify as?" ("Tuaton tii tae jing khun ben phet dai") to reflect the notion that gender identity is firmly felt and integral to one’s being. With regard to the answer choices, both the birth gender and gender identity questions contained only binary responses of ’male’ and ’female’. The responses to the gender identity question may include additional answers of ‘Not sure / Questioning’, ‘Genderfluid’, ‘Non-binary’, and ‘Do not identify as male, female, or transgender’ in order to allow respondents to identify themselves as questioning, genderfluid and gender non-binary. Youths who are in the developmental stage may be questioning their gender identity and affectional orientation [26]. Adding the option of ‘Not sure’ to the gender identity question may have allowed us to capture "Questioning youths" as a distinct group. The actual responses, however, may be further tailored to suit the context and culture of the study setting and include even more answer choices [27]. In addition, we only asked the respondents about their sex and gender identity, and not their sexual orientation. In that regard, cisgender respondents who were homosexuals and bisexuals were identified in the same group as cisgender respondents who were heterosexual. Likewise, transgender participants were also presumably grouped together without regard for their sexual identity. Future surveys should include a separate question to identify sexual orientation.

Transgender girls had a higher GPA distribution than other groups except for cisgender girls. There has been no empirical study on the underlying reason behind this distinction, but anecdotes suggest that Thai transgender women try to gain acceptance from society by educational and professional achievements [28, 29]. The relatively high GPA distribution among transgender girls could be a reflection of these endeavors during adolescence. In that regard, the literatures also suggest that Thai transgender people face discrimination and stigma in the educational system [12, 30]. Policy makers should continue to encourage academic achievements among Thai transgender youths while ensuring that youths are protected from discrimination and stigma in the educational system.

The study findings showed concerning disparities in behavioral health and experience of violence between transgender and cisgender youths. Suicidality was higher among transgender respondents than cisgender respondents, and was higher among transgender boys than transgender girls. Depression and suicidality among Thai transgender youths are associated with victimization and internalized homophobia [8, 9], as well as family rejection and social isolation [31]. The Thai media also contains hetero-sexist narratives, harmful and discriminatory rhetoric, and negative portrayals of LGBTIQ people [32]. A previous study found minority stress (i.e., stress faced by members of stigmatized minority groups caused by factors such as lack of social support, low socioeconomic status, interpersonal prejudice, and discrimination) in the Thai homosexual and bisexual men population [33]. It is possible that minority stress and internalization of rejection, discrimination and violence [9, 34] could have accounted for disparities in depression and suicidality between Thai cisgender and transgender adolescents.

With regard to drinking, transgender boys had a higher prevalence of alcohol consumption than cisgender boys, while the prevalence was lower among transgender girls. The reasons for these differences are unclear. However, it is possible that as the majority of drinkers are men [16] and drinking is perceived as a masculine activity [35], transgender boys might have felt compelled to engage in drinking or to conform to their identified gender. In addition, anecdotes suggested that Thai transgender women believe that the simultaneous use of alcohol and sex hormones can cause severe liver damage and cirrhosis and advise other transgender women against drinking [36, 37], so health concerns could also influence drinking behaviors among adolescents. Additional empirical evidence is needed to understand this disparity, and the influence of gender identity on decision to drink alcohol would be a good idea for future research. The study findings showed noticeable disparities between behavioral health of transgender and cisgender youths, and policy makers should consider adaptation and expansion of the "LGBTQIN+ Well-Being Strategies in Thailand 2021–2023" of the nationally-influential Thai Health Promotion Foundation, particularly on how to expand the strategy-driven programs to include reduction of health disparities among secondary students [38]. Such efforts can be made in collaboration with the Foundation and partner organizations in the state and civil society sectors.

One-third of respondents who identified as transgender girls reported experiencing sexual violence within the past year. Furthermore, transgender boys and transgender girls were significantly more likely than cisgender girls to experience all types of violence in the past year. A study on Thai transgender women’s experiences of stigma in daily lives showed various experiences of verbal, psychological and physical violence [12]. Although the Thai education has introduced sexuality education in its curriculum, such effort may not be effective in reducing homonegative attitudes among students [11]. The higher exposure to violence among transgender compared to cisgender respondents could be among the influences of the disparities in health behaviors. Policy makers should ensure that adequate violence prevention and support measures are in place for transgender youths in the school system, and that there are programs to address the narratives that influence the violence and discrimination. Such efforts may include but not be limited to expansion of local gender equality initiatives that aim to support both LGBTQI people and their significant others such as the 4P Project [39] and implementation of recommended policies on the Thai media’s portrayal of LGBTQI people [40].

There were several issues with measurement questions in our study. In the depression measurement question, the phrase (“…to the point where you could not do your routine daily function…”) was potentially problematic: there was no example of “routine daily function”, and some participants may not have fully understood the question, which might have contributed to measurement errors. Future studies should consider incorporating a more standardized tool such as the Thai PHQ-2 [41], which does not contain any ambiguous wording. In addition, unsafe sexual behavior assessment questions used the term “having sex” without giving any details of what this act constituted. In addition to reactivity to the presence of classmates in their proximity, participants might also have varying definitions of "having sex", and might not have considered oral or anal intercourse to be ‘sex’, despite the potential exposure risk. A nationwide survey in Thailand showed that only half of the respondents considered male-male anal sex as "having sex", while one-fourth considered oral-genital contact as "having sex" [42]. Although the mentioned survey used a different reference word for “having sex”, it is possible that such variation in definition of "having sex" also existed among our study participants. Future studies should include an introduction with a clearer definition of “having sex”. Furthermore, the question on contraceptive use pertained only to birth control measures. Transgender girls who had sex with members of the same sex (in anatomical terms) might have used condom for STD prevention but not for contraception and thus answered “No”, while others might have understood the question to pertain to both contraception and STD prevention, and might have reported condom use that was actually intended for STD prevention. In that regard, the lower condom use among transgender boys who had sex with members of the same sex (in anatomical terms) was understandable. Future studies should include a question on STD prevention methods in addition to contraception in order to obtain a clearer and more complete measure of sexual behaviors. Drug use and unsafe sexual practices are sensitive behaviors whose reports can be influenced by social desirability. A previous study suggested that interviews assisted by electronic devices are non-inferior and potentially superior to the use of self-administered questionnaires in measuring sensitive behaviors [43]. We opted for paper-and-pencil questionnaire in this study because of logistical concerns, but future surveys should consider using tablet-assisted self-interviews or audio-computer-assisted self-interviews as potential alternatives.

Strengths and limitations

The strengths of our study included the systematic classification of gender and the large sample size, which conveyed adequate statistical power to facilitate comparisons in our analyses. However, some limitations exist. First, although our survey did not include names or other identifying information, the survey was conducted in a classroom setting where proximity to other students may have given rise to the possibility of inadvertently disclosing confidential information to others. The data collection procedure, where an adult data collector came to the classroom and invited the students to participate, might not have allowed the students to feel adequately empowered to refuse to participate in the study thus compelling them to provide socially desirable answers. The fear of inadvertent disclosure and lack of empowerment to refuse to participate could have influenced the participants to provide socially desirable responses during their participation, and also presented an unforeseen ethical issue to be considered in future studies. Second, our outcomes did not include mental health outcomes that were common and significant in the health of transgender youths, such as gender dysphoria [22, 44]. Such questions should be considered for inclusion in future studies. Third, Thailand has a persistent problem of secondary school dropouts [45], thus the findings of this study could only be generalized to adolescents who remained in school.

Conclusion

We found disparities in behavioral health including depression, suicidality, unsafe sexual behaviors, alcohol and tobacco consumption, drug use, and past-year experience of violence between Thai transgender and cisgender youths. However, we could only classify the participants into four broad categories (transgender boys, transgender girls, cisgender boys, and cisgender girls) and we did not measure sexual orientation of the participants. Future studies should further modify the measurement questions to expand the contribution of the findings to LGBTQ health. The findings nonetheless provide empirical data on the health of transgender youths, and highlighted the need for program managers and policy makers to consider existing local efforts to address health gaps in the LGBTQ community and expand such efforts to the school-going youths population.

Supporting information

S1 Dataset. Anonymized data set.

Anonymized data set to replicate the study findings.

(CSV)

Click here for additional data file.^{(31.9MB, csv)}

S1 File. R codes.

Codes for data analyses, text file with annotations.

(TXT)

Click here for additional data file.^{(36.5KB, txt)}

S1 Checklist. STROBE checklist.

STROBE checklist for cross-sectional studies.

(DOCX)

Click here for additional data file.^{(28.9KB, docx)}

Acknowledgments

This study is a secondary data analysis. Primary data of the National School Survey on Alcohol Consumption, Substance Use and Other Health-Risk Behaviors 2016 were collected by the principal investigator and colleagues who allowed us to use the data.

Data Availability

All relevant data are within the paper t and its Supporting information files.

Funding Statement

The National School Survey on Alcohol Consumption, Substance Use and Other Health-Risk Behaviors 2016 was funded by the Thailand Substance Abuse Academic Network (TSAN), Thai Health Promotion Foundation. The secondary data analysis was funded by the Centre for Alcohol Studies, Thai Health Promotion Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0252520.r001

Decision Letter 0

Siyan Yi

30 Dec 2020

PONE-D-20-21445

Disparities in Behavioral Health, Experience of Violence, and Problematic Parental Behaviors Between Cisgender and Transgender Thai Adolescents

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Reviewer #1: Partly

Reviewer #2: No

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: This paper sought to deal with an important topic, the disparities in health and behavioral outcomes between cisgender and transgender adolescents in Thailand. However, this paper has several critical weaknesses.

*** Major comments

Comment 1.

A notable strength of this study is that it compares a wide variety of health outcomes, health-related behaviors, and experiences between cisgender and transgender Thai adolescents using a large, nationwide sample of school-going Thai adolescents. The study’s outcomes could be categorized into three groups.

Group 1: mental health and health behaviors

Group 2: experiences of violence

Group 3: parental addictive and violent behaviors

Currently, the results for the three groups are presented together in table 3. Analyses regarding these variables should be revisited to take into consideration for their differing implications.

First of all, it is strongly advised that the author drops variables in group 3 – parental addictive and violent behaviors – for a couple of reasons. Group 3 variables are different from group 1 and 2 variables in that they are not about the participants themselves, but about their parents. More importantly, the conclusions drawn on parental behaviors by the author (lines 400-407, page 31) can potentially be interpreted to blame transgender youths for their parents’ addictive and violent behaviors. For these reasons, the reviewer strongly recommends the author to drop group 3 variables from the study. This could be a research topic for another paper.

Second, the reviewer recommends that the results for groups 1 and 2 are presented in separate tables. Variables in group 1 are indicators of participants’ health, and variables in group 2 are about experiences of violence. It is highly possible that the experience of group 2 could be used to explain the observed health disparities of the group 1 results. It is suggested that the author first presents the results from group 1 variables and describes the health disparities between cisgender and transgender Thai adolescents. This should then be followed by results from group 2 variables in a separate table, with the discussion of these results in the context of health disparities shown in group 1 results.

Comment 2.

Although the results clearly show the health disparities experienced by transgender youths in Thailand, this paper did not provide sufficient information about the hostile social environment against transgender youth in Thailand. The author does briefly mention the negative social situations transgender youths in Thai face in the introduction (lines 57-67, pages 4-5). It is suggested that the author includes specific examples of unfair social and institutional conditions Thai transgender youths experience to better contextualize the main results.

Comment 3.

In the paper, assigned female at birth (AFAB) and assigned male at birth (AMAB) are categories of participants who did not provide an answer for the question on their gender identity. According to the paragraph that starts in line 353 of page 29, author also mentioned that they might be the people who did not understand why a separate question was asked on gender or the people who do not want reveal their gender identity, and people with missing responses. So it is evident that authors do not have enough information to understand who AFAB and AMAB actually are. Therefore, it is impossible to discuss about their findings. It is strongly recommended that the author excludes those with missing gender information from the analysis.

Comment 4.

This paper compares health statuses of Thai transgender adolescents only against their cisgender male counterparts (reference group). There is no rationale as to why cisgender male adolescents were chosen as the sole reference group to investigate health statuses of adolescents of different gender identities. Please provide a rationale as to why the author chose cisgender male adolescents as the reference group. In the events that the author cannot provide the rationale, it is suggested that they review previous works that have compared cisgender and transgender health outcomes (Downing & Przedworski, 2018; Lee et al., 2020; Thoma et al., 2019) and revise the analyses accordingly.

Downing, J. M., & Przedworski, J. M. (2018). Health of transgender adults in the US, 2014–2016. American journal of preventive medicine, 55(3), 336-344.

Lee, H., Operario, D., van den Berg, J. J., Yi, H., Choo, S., & Kim, S. S. (2020). Health disparities among transgender adults in South Korea. Asia Pacific Journal of Public Health, 32(2-3), 103-110.

Thoma, B. C., Salk, R. H., Choukas-Bradley, S., Goldstein, T. R., Levine, M. D., & Marshal, M. P. (2019). Suicidality disparities between transgender and cisgender adolescents. Pediatrics, 144(5).

Comment 5A.

The paragraph that starts at line 368 in page 30 should be revised. The paragraph is not well-organized and contains statements that are concerning. First, the author makes unnecessary comparisons with other countries (e.g. US). Since the study is not about making international comparisons of transgender youth health status, these comparisons seem unnecessary. Furthermore, the comparison sentence colludes with the findings. Table 3 shows that transgender female and transgender male adolescents have 1.82 times and 2.06 times higher odds of attempting suicide compared to cisgender male adolescents. This result, along with results of other indicators of mental health, suggests that the mental health disparities between cisgender and transgender adolescents in Thailand are severe. Despite the severity of health disparities, the author writes that suicidality in transgender adolescents is lower in Thailand when compared to other countries only to highlight the culture of acceptance of transgender identity in Thailand. The reviewer is concerned that these sentences that make comparisons may downplay the apparent severity of the mental health gap experienced by transgender adolescents in Thailand.

Comment 5B.

In the same paragraph from the comment above, the author seeks to explain the differences in mental health outcomes between transgender male and transgender female adolescents without evidence and proper citation. If authors want to discuss differences between the two populations, authors should carry out statistical analyses that directly compares the health of transgender male and transgender female adolescents to assess whether there are statistically significant differences between the two groups.

***Minor comments

Comment 1.

Table 2 shows the distribution of basic characteristics among study respondents by their gender identities. In addition to representing the distribution of the characteristics, I suggest that the author includes results of chi-square tests, to show any significantly different distributions of these characteristics among participants of different gender identities.

Comment 2.

Past research on health disparities between cisgender and transgender individuals have included measures of income or social status in their lists of covariates (Downing & Przedworski, 2018; Lee et al., 2020; Thoma et al., 2019). It is suggested that the author includes an indicator of socioeconomic status such as household income (Downing & Przedworski, 2018; Lee et al., 2020) or perceived social status (Thoma et al., 2019) as another covariate.

Downing, J. M., & Przedworski, J. M. (2018). Health of transgender adults in the US, 2014–2016. American journal of preventive medicine, 55(3), 336-344.

Lee, H., Operario, D., van den Berg, J. J., Yi, H., Choo, S., & Kim, S. S. (2020). Health disparities among transgender adults in South Korea. Asia Pacific Journal of Public Health, 32(2-3), 103-110.

Thoma, B. C., Salk, R. H., Choukas-Bradley, S., Goldstein, T. R., Levine, M. D., & Marshal, M. P. (2019). Suicidality disparities between transgender and cisgender adolescents. Pediatrics, 144(5).

Comment 3.

Depending on the outcome variable, there were varying numbers of participants dropped due to missing values. This leads to each regression having different sample sizes. Please include sample sizes, frequencies, and the proportions (%) in each of the relevant cells in tables 1, 2, and 3 to clearly provide the results with missing data.

Comment 4.

In the following sentence, “We then performed multivariate analyses to measure the association between gender classification and the outcomes adjusting for the effect of basic characteristics of the respondents using multivariate logistic regression (lines 244-246, page 14),” please include a phrase or sentence stating that the multivariate analyses were performed separately for each of the outcome variables.

Comment 5.

Please check the consistency of variable names the author used throughout the manuscript. For instance, the author used the word ‘suicidal ideation’ in the abstract and in other parts, ‘suicide contemplation’ in the method part, and ‘considered suicide’ in table 3. And in checking for the consistency, please refer to prior research for most commonly used terminology regarding your outcomes. For example, regarding suicidal behaviors, the most commonly used terminologies include ‘suicidal ideation’ and ‘suicide attempt.’

Comment 6.

There are various health outcomes and health behaviors that have high prevalence, such as 51.1% (ever drinker among transgender male adolescents) and 22.6% (prevalence of depressive experiences among transgender male adolescents). However, the author has used logistic regression for all of their analyses and reports adjusted odds ratios, which would lead to overestimation of the associations. It is suggested that the author runs a modified Poisson regression instead of logistic regression, according to the work of Zou (2004).

Zou, G. (2004). A modified Poisson regression approach to prospective studies with binary data. American Journal of Epidemiology, 159(7), 702-706.

Comment 7.

In Table 2 & 3, The N’s in the second row total out to 38,186, which is different from the n given in the title (38,189). Please check the numbers.

Comment 8.

In United States Center for Disease Control and Prevention, the overall definition of Intimate partner violence is “physical violence, sexual violence, stalking and psychological aggression (including coercive tactics) by current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner).” (Breiding, 2015, p. 11)

The perpetrators of IPV defined in your study are “significant other”, which may include family, relative, friend, or acquaintance as well as partner or spouse so on. Therefore, It is recommended to change the term to “Interpersonal violence” rather than IPV, which is used as an idiom.

Breiding, M., Basile, K. C., Smith, S. G., Black, M. C., & Mahendra, R. R. (2015). Intimate partner violence surveillance: Uniform definitions and recommended data elements. Version 2.0.

Comment 9.

Please match intext citation styles.

Comment 10.

The study shows that Thai transgender adolescents experience severe disparities in health compared to their cisgender counterparts. Please provide policy implications and/or specific programs to address this public health issue. It is also helpful to provide examples of policies and programs.

Comment 11.

There is no discussion on the disparities in experiences of violence between cisgender and transgender adolescents in Thailand. Please provide discussions according to the findings.

Comment 12.

The reasons for including ever having had sexual experience and having 4 or more partners as indicators of health-related behavior are unclear. Please provide necessary rationales for including these outcomes or consider dropping them from the analysis.

Comment 13.

Given that “male’’ and “female” are adjectives, please denote the noun that ‘male’ and ‘female’ are explaining (e.g. transgender males is wrong; it should be transgender male adolescents in this context).

Reviewer #2: This paper covers an important topic, but does it in a clumsy and incomplete manner. It fails to sufficiently engage with the literature about disparities between transgender and cisgender youth that exists in Thailand. The paper's introduction needs to be improved, its methods/procedures section needs to be shortened, the data presented in tables needs to be culled and data that is not used in the results section discussion or overall discussion needs to be removed. The use of 6 categories of youth is confusing and what AMAB and AFAB are is left to the imagination of the reader.

I suggest a very major revision.

Specific comments:

Line 39: I think the paragraph should start with an explanation of the word 'gender spectrum', i.e. that gender can be seen as a fluid, multi-dimensional concept, not as a binary term.

Line 45: sexual behaviors are not necessarily detrimental to the health of adolescents and it looks strange to see them listed on par with drug use and suicidal behaviors. I suggest to add the word 'unsafe' before 'sexual behaviors', to refer to unprotected sexual behaviors that can lead to negative outcomes such as HIV, STI or unwanted pregnancy.

Line 48: there is evidence from Thailand for this statement. See Van Griensven F, Kilmarx PH, Jeeyapant S, Manopaiboon C, Korattana S, Jenkins RA, Uthaivoravit W, Limpakarnjanarat K, Mastro TD. The prevalence of bisexual and homosexual orientation and related health risks among adolescents in northern Thailand. Archives of sexual behavior. 2004 Apr 1;33(2):137-47.

Line 49-50: there is evidence from Thailand for this statement: Guadamuz TE, Wimonsate W, Varangrat A, Phanuphak P, Jommaroeng R, McNicholl JM, Mock PA, Tappero JW, van Griensven F. HIV prevalence, risk behavior, hormone use and surgical history among transgender persons in Thailand. AIDS and Behavior. 2011 Apr 1;15(3):650-8.

and

Yadegarfard M, Ho R, Bahramabadian F. Influences on loneliness, depression, sexual-risk behaviour and suicidal ideation among Thai transgender youth. Culture, health & sexuality. 2013 Jun 1;15(6):726-37.

and

Boonchooduang N, Louthrenoo O, Likhitweerawong N, Charnsil C, Narkpongphun A. Emotional and behavioral problems among sexual minority youth in Thailand. Asian journal of psychiatry. 2019 Oct 1;45:83-7.

and

Kittiteerasack P, Matthews AK, Steffen A, Corte C, McCreary LL, Bostwick W, Park C, Johnson TP. The influence of minority stress on indicators of suicidality among lesbian, gay, bisexual and transgender adults in Thailand. Journal of Psychiatric and Mental Health Nursing. 2020 Nov 15.

and

Logie CH, Newman PA, Weaver J, Roungkraphon S, Tepjan S. HIV-related stigma and HIV prevention uptake among young men who have sex with men and transgender women in Thailand. AIDS patient care and STDs. 2016 Feb 1;30(2):92-100.

There are a few more papers on transgender and sexual minority youth from Thailand that should be reviewed / mentioned in this section, and I would suggest there is no need to include evidence from transgender people in Canada or USA, as the social and cultural context there is completely different.

Line 50-55: See above, it is not true that there is no Thai data on disparities between transgender and cisgender youth.

Line 57: Thailand is not uniformly tolerant to transgender people. Please review these papers:

Matzner A. The complexities of acceptance: Thai student attitudes towards kathoey. Crossroads: An Interdisciplinary Journal of Southeast Asian Studies. 2001 Jan 1:71-93.

Ojanen TT, Newman PA, Ratanashevorn R, de Lind van Wijngaarden JW, Tepjan S. Whose paradise? An intersectional perspective on mental health and gender/sexual diversity in Thailand.

de Lind van Wijngaarden JW, Fongkaew K. “Being Born like This, I Have No Right to Make Anybody Listen to Me”: Understanding Different Forms of Stigma among Thai Transgender Women Living with HIV in Thailand. Journal of Homosexuality. 2020 Aug 26:1-8.

Manalastas EJ, Ojanen TT, Torre BA, Ratanashevorn R, Hong BC, Kumaresan V, Veeramuthu V. Homonegativity in southeast Asia: Attitudes toward lesbians and gay men in Indonesia, Malaysia, the Philippines, Singapore, Thailand, and Vietnam. Asia-Pacific Social Science Review. 2017 Jun 1;17(1):25-33.

Line 57-61: I suggest to rewrite this, there are several surveys and studies about Thai Transgender women, but it is true that far less is known about transgender men.

Page 6 in the document is empty, suggest to remove.

Page 8-12: I suggest to remove all this information or make it shorter. There is no need to introduce each and every question asked and explain why these questions were included.

The section on Procedure should be shortened or deleted.

Line 222-230: Important to include a limitation on the methodology used. Important but little known evidence from Thailand has shown very large differences in outcomes depending on which data collection method was used. Self-administered written questionnaires resulted in lower self-reporting of 'shameful' behaviors than when a palm-top / iPad device was used for data collection. Please see: Van Griensven F, Naorat S, Kilmarx PH, Jeeyapant S, Manopaiboon C, Chaikummao S, Jenkins RA, Uthaivoravit W, Wasinrapee P, Mock PA, Tappero JW. Palmtop-assisted self-interviewing for the collection of sensitive behavioral data: randomized trial with drug use urine testing. American journal of epidemiology. 2006 Feb 1;163(3):271-8.

Line 262 - beginning of Results:

The AMAB / AFAB categories sound a bit silly, if I may say so. More explanation is needed here. Does it mean these boys and girls are gay/lesbian/bisexual/uncertain about their sexuality? It is useful to explain in the paper somewhere that Thai (at least common Thai) does not have separate words for gender and sexuality, both are referred to as 'phet'. This makes it difficult to interpret/translate. Is it possible to simplify the paper, for example by focusing only on transgender students versus cisgender students? Or is it possible to combine all cisgender students and compare them with all transgender students regardless of gender? Or include AMAB/AFAB as 1 category, transgender men&women as 1 category, and all cisgender youth as 1 category? It feels overwhelming to have so many cells and so many categories, and it becomes hard to see what the focus is and what the result of the analysis suggests. I think more work and discussion needs to go into this analysis, and maybe the focus of the paper should be better grounded in previously conducted research on this issue.

Table 3 is way too long, and contains too much information. It is almost as if the authors included the results of the questionnaire and ask the reader to do their own analysis. I suggest to be more selective in presenting information, and break the table up into several smaller tables, and maybe merge some of the sub-populations.

Line 308-310: Where does the focus on parental problems come from? Do the authors think that parents are to blame for their child being transgender? Or do they think the transgender identity of the child leads parents to have problems? I do not understand the link. Out the enormous amount of data in Table three, only a few small points are discussed in this section, and this is one of them. I do not think this section is solid enough.

Line 327-330: This suggests that AMAB may in fact be same-sex attracted youth? Apparently 'party drug' use ('ice') is high among young gay men. There are a few papers on this to review using Thai data.

Line 357: That is nonsense, using 1 study to claim that the percentage of non-normative gender identities in any given population has to be <1%. See the papers about vocational students in Northern Thailand and several other papers from Thailand that have assessed the prevalence of homosexual/bisexual orientation and transgender identities, and they are all much higher than 1%.

Line 367: This is an interesting finding. In comparison, see this paper: https://www.sciencedirect.com/science/article/abs/pii/S0049089X16308468

Line 370-376: When discussing Thai media reporting on LGBTQ people, I suggest to review and reference this paper:

Fongkaew K, Khruataeng A, Unsathit S, Khamphiirathasana M, Jongwisan N, Arlunaek O, Byrne J. “Gay Guys are Shit-Lovers” and “Lesbians are Obsessed With Fingers”: The (Mis) Representation of LGBTIQ People in Thai News Media. Journal of homosexuality. 2019 Jan 28;66(2):260-73.

Line 408-418 should move to the limitations section below.

413-418: Very good point.

Conclusion is very short. If this is what the paper is about, it will be easy to slim it down, removing all other information presented in tables but not discussed.

Reviewer #3: Overall, I think that the large sample size, robust sampling strategy, and wide selection of variables makes this study a very worthy contribution to the literature on transgender mental health in Thailand. Below, I make some observations and suggestions that I hope will be helpful to contextualizing the findings better.

Terminology: The terms "transgender male" and "transgender female" are a bit confusing. "Male" and "female" are often used to refer to biological sex rather than self-ascribed gender; having read the abstract, I am still unsure whether "transgender male" and "transgender female" refer to individuals of male or female birth sex, and consider themselves boys or girls. Wonder if the abstract word limit makes it possible to clarify the terms in brief there as well? Also, given that the entire study was on adolescents, it might make sense using "transgender boys," "transgender girls" and "cisgender boys," "transgender girls" respectively (the terms "boys" and "girls" might capture the self-ascribed gender better than the strictly biological terms "male" or "female").

lines (l.) 59 - 67: There are quite a few studies conducted in Thailand especially on violence and depression that you might want to take into account here - they may not use exactly the same kind of disaggregation as the present study, but are nevertheless relevant. In the light of these studies, in particular the statement (l. 59-60) that existing studies are based on small-scale surveys or qualitative data is not exactly accurate (e.g., https://doi.org/10.1080/13691058.2020.1737235 ; https://doi.org/10.1371/journal.pone.0237707 ; https://doi.org/10.1080/10826084.2019.1638936 ; http://unesdoc.unesco.org/images/0022/002275/227518e.pdf ; https://so03.tci-thaijo.org/index.php/jpss/article/view/102396) ; Table 5 in the Plan International Thailand report on school bullying that relies on self-reported level of masculinity uses a proxy variable for disaggregating transgender and gender-nonconforming youth from those who are gender conforming.

l. 130 Wonder if the Thai terminology used for "sexual intercourse" made it clear to participants what kind of sex was being asked about? And did the participants understand it in the same way as the researchers? There is some older evidence that many Thai people don't count oral or anal contact as "intercourse" - see p. 33 in the following article: https://doi.org/10.1300/J041v09n02_02 - it might be good to reflect on whether this poses any limitations to the validity of the analyses? I see that later in the article, the Limitations section notes this, but the above article may help to contextualize this concern.

l. 142 It may be good to note the limits of a question on contraception in, for example, male-male or female-female sexual acts (is it understood by 1-the survey makers and 2-adolescents to refer to birth control only, or to preventing STDs and HIV as well?). This links to the lowered odds ratio of "trans males" using condoms according to Table 3 - most of them are likely to have had sex with females, so it's (in anatomical terms) female-female sex, where condom use is understandably less common than in male-female or male-male sex).

Table 1. The high percentage of participants not answering the "gender identity" question might be a result of the participants' confusion in being asked about their identity and yet being given only two response options (because an identity question corresponding to the Thai understanding of self-defined phet might rather give a long list of locally recognized identities, such as man, woman, kathoey, gay, tom, dee, etc. where gender identity and sexual orientation are aspects of the same categorical folk identity construct "phet"- see Table 1 in the Plan International report noted above for an example; my guess would be that those identifying as gay, bi, dee, etc. might be quite prevalent among those not answering the second question on their self-ascribed phet). ... this also provides clues to locally relevant response options to the survey as discussed in lines 338-342. It also calls into question whether the statement in lines 347-349 about homosexual and heterosexual persons of the same gender identity being grouped together is correct, and provides an alternative explanation to the statement in lines 356-360.

Table 2. Wonder if providing by-row rather than by-column percentages would be more useful to the reader? This would make it easier to compare the prevalence of each gender/sex group across types of demographic groups.

l. 364 The statement of there being little discrimination from teachers is questionable. For example, a World Bank commissioned survey ( http://documents1.worldbank.org/curated/en/319291524720667423/pdf/124554-v2-main-report-Economic-Inclusion-of-LGBTI-Groups-in-Thailand-Report-Thai-Version-PUBLIC.pdf ) found that 23% of transgender adults reported having been discriminated in education (p. 40). However, there may be a difference in discrimination from teachers as individuals versus educational institutes as institutions.

l. 368-389 The suicidality figures and their possible antecedents should be compared with some of the studies on Thai adolescents I mentioned above. There are also other studies that may be relevant, such as emerging Thai studies on LGBTIQ adults (e.g., https://doi.org/10.1111/jpm.12713 ) or a couple of earlier articles on Thai youth using convenience samples (https://doi.org/10.1080/19361653.2014.910483 ; http://dx.doi.org/10.1080/13691058.2013.784362 ).

l. 404 Footnote style citation missing for Katz-Wise et al

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PLoS One. 2021 May 28;16(5):e0252520. doi: 10.1371/journal.pone.0252520.r002

Author response to Decision Letter 0

26 Feb 2021

Dear Reviewers,

My co-authors and I would like to thank you for the constructive and thoughtful comments. We have responded to them on a point-by-point basis in the "Response to Reviewers.docx" document. We thank you for your kind consideration and we look forward to hearing from you.

Sincerely Yours,

Corresponding Author

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PLoS One. doi: 10.1371/journal.pone.0252520.r003

Decision Letter 1

Siyan Yi

7 Apr 2021

PONE-D-20-21445R1

Disparities in Behavioral Health and Experience of Violence between Cisgender and Transgender Thai Adolescents

PLOS ONE

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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: All comments have been addressed

Reviewer #3: (No Response)

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

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #2: No

Reviewer #3: Yes

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6. Review Comments to the Author

Reviewer #2: Dear authors

I think you have done a stellar job addressing my (and other reviewers') comments.

I have only two minor points. While I am glad you clarified the issue of acceptance/tolerance of transgender people in Thai society somewhat, I do not think the level of 'homonegativity' in Thailand is higher than in neighboring countries, that would take the statement too far! It is a pity you could not access the Matzner paper I sugggested, it is really fascinating and would provide a theoretical explanation for the contradictions that characterise this issue in Thai society; maybe a colleague with access to paid content can find it for you?

Also when describing that half of respondents would consider male-male sex to be 'sex', I would add the word 'only'...

I.e. only half of the participants.... This is an important and striking finding :)

I like it that you have include linguistic challenges regarding gender/sexuality and agree that sexual orientation is another complicating factor.

In general, I suggest a final edit by a native English speaker, and then I think the paper should be ready for publication.

Best wishes

Jan ยันต์

Reviewer #3: I feel the article is overall in much better shape now, following the authors' extensive edits to the manuscript. My comments below are mostly minor language edits and corrections to wordings the authors may have forgotten to adjust following overall changes to the manuscript. Once these have been fixed, I think the paper will be ready for publication.

Minor comments:

Abstract:

- "identified as transgenders" -> "identified as transgender"

- "higher prevalence suicidal ideation" -> "had a higher prevalence of suicidal ideation"

- "school-going youths population" -> "the school-going youth population"

Introduction:

- watch out for unnecessary use of "still" (e.g., l. 58, 59)

l. 56: Would be helpful to clarify what kinds of risk behavior. Sexual? Substances? Extreme sports?

l. 58-59: "still has higher prevalence of homonegativity..." To represent Manalastas et al. more accurately, you could state that the level of homonegative attitudes in Thailand is higher than in some other countries in the region, and lower than in others (better still, state which SE Asian countries included in the study are more and which countries are less homonegative than Thailand)

l. 60 "despite perception as a safe haven" -> "although many perceive it as a safe haven"

l 61 "transgender youths are" -> "transgender youth"

l. 68-69 "as well as parental issues related to addiction and violence," -> remove if no longer included in analyses

l. 72 "sex assigned at birth (sex)" -> "sex assigned at birth"

l. 74 "and parental problematic behaviors" -> remove if no longer included in analyses

l. 116 Does "withdrawal" here refer to the withdrawal method of contraception (coitus interruptus)? Please clarify if the original survey item implied this.

l. 141 "Sexual violence" -> "sexual violence"

l. 167-168 "and parental addictive and violent behaviors)" -> remove if no longer included

l. 196-197 "Transgender females and transgender males" -> adjust in keeping with revised terminology

l. 223 "had significantly prevalence of lifetime" -> "had significantly higher prevalence of lifetime"

l. 259 "What gender do you identify as?" - in this case, which Thai words would you use to translate "gender" and "identify" so as to understandable to school-age kids? If you have a suggestion for these, you might include the transcription of your preferred Thai words for these terms in brackets after the word; this would be useful to other researchers

l. 263 Considering current developments of gender identity in Thailand, including "non-binary" as a response option would also make sense

l. 290 "minority stress" (you could give a brief definition for it)

l. 294-295 change terminology to match the rest of the article (transgender males->transgender boys; cisgender males->cisgender boys; transgender females->transgender girls)

l. 297 "transgender students" -> "transgender boys" (their aspiration to masculinity is the key point here)

l. 316 "These higher" -> "The higher"

l. 322 "the 4P Project" - instead of the cited popular-press article, please cite the project report, which has now been completed and is available at https://lsed.tu.ac.th/uploads/lsed/pdf/research/%20LGBT4P.pdf

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Reviewer #2: No

Reviewer #3: Yes: Timo Tapani Ojanen

PLoS One. 2021 May 28;16(5):e0252520. doi: 10.1371/journal.pone.0252520.r004

Author response to Decision Letter 1

27 Apr 2021

Response to Reviewers

PONE-D-20-21445R1

Disparities in Behavioral Health and Experience of Violence between Cisgender and Transgender Thai Adolescents

Reviewers' comments:

Reviewer #2:

COMMENT: I think you have done a stellar job addressing my (and other reviewers') comments.

RESPONSE: Thank you so much

COMMENT: I have only two minor points. While I am glad you clarified the issue of acceptance/tolerance of transgender people in Thai society somewhat, I do not think the level of 'homonegativity' in Thailand is higher than in neighboring countries, that would take the statement too far! It is a pity you could not access the Matzner paper I sugggested, it is really fascinating and would provide a theoretical explanation for the contradictions that characterise this issue in Thai society; maybe a colleague with access to paid content can find it for you?

RESPONSE: We thank the reviewer for the suggestion. We decided to revise the opening sentence in the third paragraph of the INTRODUCTION section to the following:

“Thailand is a middle-income country in South East Asia that experiences homonegativity, not unlike other countries in the region[10].”

COMMENT: Also when describing that half of respondents would consider male-male sex to be 'sex', I would add the word 'only'...

I.e. only half of the participants.... This is an important and striking finding :)

RESPONSE: Agree. The sentence has been revised as follows:

“A nationwide survey in Thailand showed that only half of the respondents considered male-male anal sex as "having sex", while one-fourth considered oral-genital contact as "having sex"[42]”

COMMENT: I like it that you have include linguistic challenges regarding gender/sexuality and agree that sexual orientation is another complicating factor.

RESPONSE: Thank you

COMMENT: In general, I suggest a final edit by a native English speaker, and then I think the paper should be ready for publication.

Best wishes

Jan ยันต์

RESPONSE: Thank you very much for the compliments and constructive comments ขอบคุณครับ

Reviewer #3

COMMENT: I feel the article is overall in much better shape now, following the authors' extensive edits to the manuscript. My comments below are mostly minor language edits and corrections to wordings the authors may have forgotten to adjust following overall changes to the manuscript. Once these have been fixed, I think the paper will be ready for publication.

RESPONSE: Thank you. The other reviewer, a native speaker of English, has graciously provided detailed instructions for language edits, which we have followed and made changes throughout the manuscript.

Minor comments:

Abstract:

COMMENT:

- "identified as transgenders" -> "identified as transgender"

- "higher prevalence suicidal ideation" -> "had a higher prevalence of suicidal ideation"

- "school-going youths population" -> "the school-going youth population"

RESPONSE: Thank you for the suggestions. We have made changes accordingly.

Introduction:

COMMENT: - watch out for unnecessary use of "still" (e.g., l. 58, 59)

RESPONSE: The first two sentences of the third paragraph of the INTRODUCTION section has been revised as follows:

“Thailand is a middle-income country in South East Asia that experiences homonegativity, not unlike other countries in the region[10]. Although many perceive the country as a safe haven[11], Thai transgender women do report experiences of discrimination and violence[12].”

COMMENT: l. 56: Would be helpful to clarify what kinds of risk behavior. Sexual? Substances? Extreme sports?

RESPONSE: To avoid redundancy in mentioning citation [5] twice, we changed the middle part of the second paragraph to the following:

“Behavioral health issues affect both transgender and cisgender adolescents, although a previous study has shown disparities in the prevalence of unsafe sexual practices, sexual violence, drug use, and depression [5].”

COMMENT: l. 58-59: "still has higher prevalence of homonegativity..." To represent Manalastas et al. more accurately, you could state that the level of homonegative attitudes in Thailand is higher than in some other countries in the region, and lower than in others (better still, state which SE Asian countries included in the study are more and which countries are less homonegative than Thailand)

RESPONSE: We thank the reviewer for the comment. The other reviewer has also commented on this sentence and remarked that they “do not think the level of 'homonegativity' in Thailand is higher than in neighboring countries, that would take the statement too far!...”

Therefore, as a compromise, we decided to revise the first two sentences of the third paragraph of the INTRODUCTION section to the following:

COMMENT: l. 60 "despite perception as a safe haven" -> "although many perceive it as a safe haven"

RESPONSE: Change made

COMMENT: l 61 "transgender youths are" -> "transgender youth"

RESPONSE: Sentence revised as follows:

“Although many perceive the country as a safe haven[11], Thai transgender women do report experiences of discrimination and violence[12].”

COMMENT: l. 68-69 "as well as parental issues related to addiction and violence," -> remove if no longer included in analyses

RESPONSE: Removal made

COMMENT: l. 72 "sex assigned at birth (sex)" -> "sex assigned at birth"

RESPONSE: Change made

COMMENT: l. 74 "and parental problematic behaviors" -> remove if no longer included in analyses

RESPONSE: Removal made

COMMENT: l. 116 Does "withdrawal" here refer to the withdrawal method of contraception (coitus interruptus)? Please clarify if the original survey item implied this.

RESPONSE: Yes. The most direct translation of the question item would be “external ejaculation” (“หลั่งภายนอก”), which (I believe) corresponds to coitus interruptus. We have revised the term to the following:

“Withdrawal (coitus interruptus)”

COMMENT: l. 141 "Sexual violence" -> "sexual violence"

RESPONSE: Change made

COMMENT: l. 167-168 "and parental addictive and violent behaviors)" -> remove if no longer included

RESPONSE: Change made

COMMENT: l. 196-197 "Transgender females and transgender males" -> adjust in keeping with revised terminology

RESPONSE: Changed to “Transgender girls and transgender boys”

COMMENT: l. 223 "had significantly prevalence of lifetime" -> "had significantly higher prevalence of lifetime"

RESPONSE: Change made

COMMENT: l. 259 "What gender do you identify as?" - in this case, which Thai words would you use to translate "gender" and "identify" so as to understandable to school-age kids? If you have a suggestion for these, you might include the transcription of your preferred Thai words for these terms in brackets after the word; this would be useful to other researchers

RESPONSE: That’s an interesting question. We feel that the word "ตัวตน" would be an appropriate translation of "identity" for the target population. Actually, we changed the wording in the 2020 student health survey questionnaire from "เพศวิถี (คุณคิดว่าคุณเป็นเพศ...)" to "เพศวิถี (ตัวตนคุณที่แท้จริงเป็นเพศใด)". During the pilot-testing of the questionnaire, no student expressed confusion with regard to the question wording. That said, we feel that such suggestion using the word ตัวตน alone without its context would not be as useful to future researchers. Thus we have included the transcription of the original and preferred Thai words in their sentences in the revised manuscript as follows:

“Future studies should consider modification of the gender identity measurement question to help reduce this non-response, e.g., changing from "You think you are..." ("Khun kid waa khun ben phet...") to "What gender do you identify as?" ("Tuaton tii tae jing khun ben phet dai") to reflect the notion that gender identity is firmly felt and integral to one's being”

COMMENT: l. 263 Considering current developments of gender identity in Thailand, including "non-binary" as a response option would also make sense

RESPONSE: Change made

COMMENT: l. 290 "minority stress" (you could give a brief definition for it)

RESPONSE: Sentenced revised as follows:

“A previous study found minority stress (i.e., stress faced by members of stigmatized minority groups caused by factors such as lack of social support, low socioeconomic status, interpersonal prejudice, and discrimination) in the Thai homosexual and bisexual men population[33].”

COMMENT: l. 294-295 change terminology to match the rest of the article (transgender males->transgender boys; cisgender males->cisgender boys; transgender females->transgender girls)

RESPONSE: Changes made

COMMENT: l. 297 "transgender students" -> "transgender boys" (their aspiration to masculinity is the key point here)

RESPONSE: Change made

COMMENT: l. 316 "These higher" -> "The higher"

RESPONSE: Change made

COMMENT: l. 322 "the 4P Project" - instead of the cited popular-press article, please cite the project report, which has now been completed and is available at https://lsed.tu.ac.th/uploads/lsed/pdf/research/%20LGBT4P.pdf

RESPONSE: We have added the new reference to replace the existing one

Attachment

Submitted filename: Response to Reviewers 20210427.docx

Click here for additional data file.^{(26.2KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0252520.r005

Decision Letter 2

Siyan Yi

18 May 2021

Disparities in Behavioral Health and Experience of Violence between Cisgender and Transgender Thai Adolescents

PONE-D-20-21445R2

Dear Dr. Wichaidit,

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,

Siyan Yi, MD, MHSc, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0252520.r006

Acceptance letter

Siyan Yi

20 May 2021

PONE-D-20-21445R2

Disparities in Behavioral Health and Experience of Violence between Cisgender and Transgender Thai Adolescents

Dear Dr. Wichaidit:

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,

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on behalf of

Dr. Siyan Yi

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Dataset. Anonymized data set.

Anonymized data set to replicate the study findings.

(CSV)

Click here for additional data file.^{(31.9MB, csv)}

S1 File. R codes.

Codes for data analyses, text file with annotations.

(TXT)

Click here for additional data file.^{(36.5KB, txt)}

S1 Checklist. STROBE checklist.

STROBE checklist for cross-sectional studies.

(DOCX)

Click here for additional data file.^{(28.9KB, docx)}

Attachment

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Click here for additional data file.^{(56.2KB, docx)}

Attachment

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Click here for additional data file.^{(26.2KB, docx)}

Data Availability Statement

All relevant data are within the paper t and its Supporting information files.

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Disparities in behavioral health and experience of violence between cisgender and transgender Thai adolescents

Wit Wichaidit

Sawitri Assanangkornchai

Virasakdi Chongsuvivatwong

Roles

Abstract

Background

Methods

Results

Conclusion

Introduction

Materials and methods

Study design and participants

Instrumentation: Measurement of gender

Table 1. Gender classification definitions of respondents and proportions, weighted percent ± standard error (SE) (n = 31,898 respondents).

Instrumentation: Behavioral health

Instrumentation: Measurement of experience of violence

Instrumentation: Demographic characteristics

Procedure

Data analysis

Ethical considerations

Results

Table 2. Characteristics of study respondents, weighted percent ± SE unless otherwise noted (n = 31,898 respondents).

Table 3. Prevalence (weighted percent ± SE) and adjusted prevalence ratios (APRs) of mental health outcomes and health behaviors among respondents, stratified by gender.

Table 4. Prevalence (weighted percent ± SE) and adjusted odds ratios (AORs) of past-year exposure to violence among respondents of the TSSHRBS, stratified by gender.

Discussion

Strengths and limitations

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Siyan Yi

Roles

Author response to Decision Letter 0

Decision Letter 1

Siyan Yi

Roles

Author response to Decision Letter 1

Decision Letter 2

Siyan Yi

Roles

Acceptance letter

Siyan Yi

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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