Social Determinants of Health Influence on Trans and Gender-Diverse People: A Qualitative Photovoice Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a timely, well-motivated participatory photovoice study that addresses how social determinants of health (SDOH) shape the lives and well-being of transgender and gender-nonconforming (TGNC) people in the Region of Murcia. The manuscript provides rich participant-generated images and texts, clear attention to empowerment aims, and practitioner-oriented implications for nursing and regional policy. However, in its current form, the paper requires major revision to make its analytic procedures, sampling logic, translation/reflexivity practices, and policy inferences explicit and auditable. Below, I give a section-by-section review.

Introduction

The Introduction situates the study in SDOH and intersectionality literatures and makes an appropriate case for photovoice as both an expressive and policy-oriented method. However, I would recommend starting with 1 to 2 paragraphs that name (a) setting (Region of Murcia, Spain), (b) population (adult TGNC people), and (c) stakes (mental health, access to gender-affirming care, employment/exclusion). This orients readers immediately and prevents the current oscillation between prevalence, methods, and policy. Furthermore, replace the scattered background with a synthesized paragraph each on (a) SDOH/minority stress and TGNC health, (b) participatory arts-based methods (photovoice) in gender research, and (c) Spanish/regional policy context (refer explicitly to Ley 4/2023 and regional protocol timing). Also, then conclude the introduction with an explicit research question and a clear statement of contribution.

 

Methods

The PAR + photovoice design, SHOWED prompts, session sequence, and use of ATLAS.VTi v8 is an appropriate choice for the aims. Ethical approvals and COREQ references are present. However, state how many people were invited, the practical application of inclusion/exclusion criteria, and whether outreaches beyond associations/social media were attempted. Add an explicit paragraph acknowledging the networked nature of recruitment and its implications for transferability (e.g. likely under-representation of highly isolated TGNC people). Table I should add columns for association membership and years since transition to clarify heterogeneity. Furthermore, give precise counts and durations for the five PAR cycles (e.g. number of focus-group meetings, mean session length), name facilitator roles (initials + role), and state dates/venues (already partly reported, make exact).

 

Also declare who translated Spanish transcripts and photovoice texts into English for analysis/writing, whether back-translation or bilingual checks were performed, and how idiomatic expressions were handled. If participant checking of translated quotes occurred, state it; if not, explain. This is critical because translation choices directly affect interpretive claims. Additionally, provide a short boxed worked example: one raw photovoice caption/transcript excerpt → line-by-line initial codes → how codes were grouped → theme label. State who coded (initials/roles), that coding was done in pairs, how consensus meetings were conducted (frequency, decision rule), and whether any audit or inter-coder checks were applied. Explain how photographs and SHOWED texts were integrated in the codebook (visual + textual triangulation). Without this analytic trace, readers cannot judge the link from data to theme.

 

Moreover, expand the reflexivity paragraph to include team positionalities (discipline, institutional ties, any insider relations), how power was handled in PAR sessions, and specific bias-mitigation steps (rotating facilitation, independent coding, managing the one participant related to a team member). This should be short but explicit.

Results

To further sharpen your results, for each major theme add 2 to 4 representative verbatim extracts (typical + divergent) and, where helpful, indicate breadth (e.g. “reported by 5 of 7 participants”). This is not a positive quantification but aids readers’ judgment of saturation and scope. When institutional documents or researcher observations are invoked, separate these clearly from participant testimony. Also, reiterate in results the consent procedure for images, anonymisation steps, and how images will be presented in the article (with participant permission). If images are reproduced, captions must note participant-generation and consent.

Discussion

The Discussion draws on minority stress and SDOH frameworks and acknowledges photovoice’s potential for empowerment. However, there is room for improvement. First, map each empirical theme onto theoretical frameworks (minority stress, intersectionality), showing how the evidence confirms/complicates these frames. Second, theorize the mechanisms operating in Murcia (local protocol timing, cultural stigma, employment structure) that explain the observed patterns. Third, derive prioritized, evidence-linked interventions. Use short subheadings for each move to improve clarity.

From general to specific policy steps. Translate suggestions into a short, prioritized list (short/medium/long term), each tied to a quoted empirical finding. E.g. because fear of disclosure emerged, recommend an anonymous initial screening + confidential liaison officer outside academic/clinical teams, with a short rationale and resource note (who implements primary care, regional health authority, nurse-led liaison): Prioritize and flag responsible stakeholders.

Lastly, expand the limitations beyond small N/single site to discuss selection bias from association/social media recruitment, translation risks (nuance loss), potential facilitation effects from team positionality, and the limits introduced by fluctuating attendance. Suggest concrete future work (multi-site comparative PAR, inclusion of less-connected TGNC people, participatory co-analysis with community researchers).

Author Response

Please see the attachment. Thank you for your time and review.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The study forms an important topic to be raised, and an interesting method is applied here, however I think the whole structure (too many paragraphs, very limited interpretation, the introductory part is strongly misleading - it does not point at the problem of the paper be it gender itentidy or transgender people?? It does need strong re-reading and reconstruction (see exemplary qualitative works using photovoice as method perhaps). 

• it has several serious methodological flaws: the "group" (it may be rather a 7-case studies here...), conceptualization (I don't know whether it is on sex on gender or transgener, or genderfuild or non-binary, these are not the same terms! stronger conceptualization is needed and if the group in question is so heterogenic then resubmit with a case-study methodology)
• there is little attention paid to the rigorous qualitative research and the research outcomes are presended in a limited way, also its interpretations are limited and sometimes truistic
• the English needs improvement in terms of misuse of certain vocabulary or stylistics (strong proofreading needed) 

 

Gender identity is the internal, personal experience of gender, independent of the sex 32
assigned at birth. From this perspective, a trans person is someone who does not identify 33
with their assigned sex, and the term ‘non-binary’ is used to describe identities which do 34
not conform to the male/female binarism

 

• i think there is a strong misconception here. transgenderism is not non-binarism!

 

.1. Participants

 

• including statistics on a 7 group is a misunderstanding, it is a qualitative study after all

Inclusion criteria were: (1) non-hegemonic gender identity;

 

What is non-hegemonic gender identity? it is not a psychological term. In overall there is much incoherence in terminology over the article, and it is weakly associated with the current literature of the subject

Author Response

Please see the attachment. Thank you for your time and review.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I am satisfied with the authors' revisions and have no further comments or feedback. There are minor language and grammar issues, and I suggest a thorough proofreading before its publication. 

Reviewer 2 Report

Comments and Suggestions for Authors

Reviewer's remarks have ben thoroughly applied.