Overview of Medical Management of Transgender Men: Perspectives from Sri Lanka

Round 1

Reviewer 1 Report

Overview of the management of transgender men: Perspectives from a South Asian country

This is an interesting and relevant review. A few changes would improve the overall quality of the paper:

1. Title: I would suggest authors to change the title into: “Overview of the medical management of transgender men: Perspectives from Sri Lanka”
2. Abstract: rewrite accordingly to the title change.
3. I would suggest authors to include information on the Gynecological care for trans men who do not undergo surgery.
4. I suggest authors to expand topics 5, 6, 7, and 8, since information is disproportionately little here.
5. Regarding topic 6 (mental health) please include mental health disparities for trans men and the importance of psychiatric/psychological assessment and interventions.
6. Please include information regarding the importance of assisting trans men in their self-affirmative journey, the importance of interacting with trans community groups or activists.
7. Please include information on the importance of providing medical training in Sri Lanka that includes topics on transgender health.

Best wishes.

Author Response

Dear Editor-in-Chief,

Re: Review article for publication – “Overview of the management of transgender men perspectives from Sri Lanka”

Thank you for reviewing our manuscript titled “Overview of the management of transgender men perspectives from Sri Lanka” for publication in your esteemed journal. We also wish to thank the reviewers for providing us with very relevant and useful comments to improve our manuscript. We have revised our manuscript based on reviewers’ comments and a revised version of the manuscript with all revisions in highlighted font is submitted. Please find a detailed response to reviewers with explanatory notes on revisions we have made to the manuscript (see below).

Once again, thank you for considering our manuscript for publication in your prestigious journal and we expect to hear from you at your earliest convenience.

Yours sincerely,

Corresponding Author

Reviewer(s)' Comments to Author:

Reviewer: 1

1. Title: I would suggest authors to change the title into: “Overview of the medical management of transgender men: Perspectives from Sri Lanka”

Authors’ response: Thank you for the suggestion. We have revised the title accordingly.

1. Abstract: rewrite accordingly to the title change.

Authors’ response: Thank you for the suggestion. We have revised the abstract according to the revised title.

1. I would suggest authors to include information on the Gynecological care for trans men who do not undergo surgery

Authors’ response: Thank you for your suggestions. We have incorporated a section on gynaecological care (Section 5)

1. I suggest authors to expand topics 5, 6, 7, and 8, since information is disproportionately little here.

Authors’ response: Thank you for your valuable suggestions. We have expanded the relevant sections. (Please see new sections 6,7,8 and 9)

1. Regarding topic 6 (mental health) please include mental health disparities for trans men and the importance of psychiatric/psychological assessment and interventions.

Authors’ response: Thank you for your suggestions. We have incorporated the suggested change (section 7, page 5).

1. Please include information regarding the importance of assisting trans men in their self-affirmative journey, the importance of interacting with trans community groups or activists.

Authors’ response: Thank you for your suggestions. We have incorporated the suggested change in section 10, page 7.

1. Please include information on the importance of providing medical training in Sri Lanka that includes topics on transgender health.

Authors’ response: Thank you for your suggestions. We have incorporated the suggested change in section 11, page 7.

Reviewer: 2

Comments to the Author

This paper looks at FtM transgender people in a South Asian context and provides new information mainly in relation to the new geographic location. The literature review is the basis of a strong paper with some good information from US sources in the main, which should be augmented from other Asia-pacific sources where possible. 

On binary and non-binary identity, it may be important to note that studies have shown that most FtM transgender (transmen) see themselves as 'men' or 'male', and the most common preferred surgery is chest surgery [Jones, T., del Pozo De Bolger, A., Dunne, T., Lykins, A. and Hawkes, G. (2015). Female-to-Male (FtM) Transgender People's Experiences in Australia. Cham, Switzerland: Springer. ISBN 978-3-319-13829-9]. However, it is also worth noting the shift in identity over time. Now, half of young transgender people identify as non-binary [Smith et al. 2014. From Blues to Rainbows. Melbourne: ARCSHS].

Authors’ response: Thank you for your suggestions. We have incorporated the suggested sentences and the references. (Sections 4.1, page 3 and Section 6, page 5)

On cancer, there has been some research on combatting dysphoria that occurs in high rates in the interactions during cancer care, that is important to note. It would be important to establish that cancer care can be delivered in discriminatory ways or withheld by some doctors for these patients. Around page 3 line 103 it would be useful to then note the call for FtM transgender patients (transmen) to be treated with less discrimination - for example to be asked which words they prefer to use for their body parts, or to use words that are not gendered like chest and genitals (rather than for example, breast tissue or vagina). Some references:

Riggs, D., & Due, C. (2013). Gender Identity Australia: The healthcare experiences of people whose gender identity differs from that expected of their natally assigned sex. Adelaide: School of Social and Policy Studies, Flinders University.

Schulz, S. L., Kamens, S. R., Robbins, B. D., & Flanagan, E. H. (2018). The Informed Consent Model of Transgender Care: An Alternative to the Diagnosis of Gender Dysphoria. Journal of Humanistic Psychology, 58(1), 72-92.  

Silverberg, M. J., Nash, R., Becerra-Culqui, T. A., Cromwell, L., Getahun, D., Hunkeler, E., . . . Goodman, M. (2017). Cohort study of cancer risk among insured transgender people. Annals of Epidemiology, 27(8), 499-501.

Authors’ response: Thank you for your valuable suggestions. We have incorporated the suggested changes and the references in section 3 page 3.

These studies also noted improvements in FtM transgender people after some form of gender affirmation, however affirmations could vary from social, to medical for example. It may be worth emphasising the differences in options (that some prefer only social changes) a little more, and that this may or may not align with binary and non-binary identities... this is a little unclear in the piece as it currently stands. Otherwise, a great piece overall!

Authors’ response: Thank you for your valuable suggestions. We have revised the manuscript based on your comments Section 1, page 2.

Author Response File: Author Response.pdf

Reviewer 2 Report

This paper looks at FtM transgender people in a South Asian context and provides new information mainly in relation to the new geographic location. The literature review is the basis of a strong paper with some good information from US sources in the main, which should be augmented from other Asia-pacific sources where possible. 

On binary and non-binary identity, it may be important to note that studies have shown that most FtM transgender (transmen) see themselves as 'men' or 'male', and the most common preferred surgery is chest surgery [Jones, T., del Pozo De Bolger, A., Dunne, T., Lykins, A. and Hawkes, G. (2015). Female-to-Male (FtM) Transgender People's Experiences in Australia. Cham, Switzerland: Springer. ISBN 978-3-319-13829-9]. However, it is also worth noting the shift in identity over time. Now, half of young transgender people identify as non-binary [Smith et al. 2014. From Blues to Rainbows. Melbourne: ARCSHS].

On cancer, there has been some research on combatting dysphoria that occurs in high rates in the interactions during cancer care, that is important to note. It would be important to establish that cancer care can be delivered in discriminatory ways or withheld by some doctors for these patients. Around page 3 line 103 it would be useful to then note the call for FtM transgender patients (transmen) to be treated with less discrimination - for example to be asked which words they prefer to use for their body parts, or to use words that are not gendered like chest and genitals (rather than for example, breast tissue or vagina). Some references:

Riggs, D., & Due, C. (2013). Gender Identity Australia: The healthcare experiences of people whose gender identity differs from that expected of their natally assigned sex. Adelaide: School of Social and Policy Studies, Flinders University.

Schulz, S. L., Kamens, S. R., Robbins, B. D., & Flanagan, E. H. (2018). The Informed Consent Model of Transgender Care: An Alternative to the Diagnosis of Gender Dysphoria. Journal of Humanistic Psychology, 58(1), 72-92.  

Silverberg, M. J., Nash, R., Becerra-Culqui, T. A., Cromwell, L., Getahun, D., Hunkeler, E., . . . Goodman, M. (2017). Cohort study of cancer risk among insured transgender people. Annals of Epidemiology, 27(8), 499-501.

These studies also noted improvements in FtM transgender people after some form of gender affirmation, however affirmations could vary from social, to medical for example. It may be worth emphasising the differences in options (that some prefer only social changes) a little more, and that this may or may not align with binary and non-binary identities... this is a little unclear in the piece as it currently stands. Otherwise, a great piece overall!

Author Response

Dear Editor-in-Chief,

Re: Review article for publication – “Overview of the management of transgender men perspectives from Sri Lanka”

Thank you for reviewing our manuscript titled “Overview of the management of transgender men perspectives from Sri Lanka” for publication in your esteemed journal. We also wish to thank the reviewers for providing us with very relevant and useful comments to improve our manuscript. We have revised our manuscript based on reviewers’ comments and a revised version of the manuscript with all revisions in highlighted font is submitted. Please find a detailed response to reviewers with explanatory notes on revisions we have made to the manuscript (see below).

Once again, thank you for considering our manuscript for publication in your prestigious journal and we expect to hear from you at your earliest convenience.

Yours sincerely,

Corresponding Author

Reviewer(s)' Comments to Author:

Reviewer: 1

1. Title: I would suggest authors to change the title into: “Overview of the medical management of transgender men: Perspectives from Sri Lanka”

Authors’ response: Thank you for the suggestion. We have revised the title accordingly.

1. Abstract: rewrite accordingly to the title change.

Authors’ response: Thank you for the suggestion. We have revised the abstract according to the revised title.

1. I would suggest authors to include information on the Gynecological care for trans men who do not undergo surgery

Authors’ response: Thank you for your suggestions. We have incorporated a section on gynaecological care (Section 5)

1. I suggest authors to expand topics 5, 6, 7, and 8, since information is disproportionately little here.

Authors’ response: Thank you for your valuable suggestions. We have expanded the relevant sections. (Please see new sections 6,7,8 and 9)

1. Regarding topic 6 (mental health) please include mental health disparities for trans men and the importance of psychiatric/psychological assessment and interventions.

Authors’ response: Thank you for your suggestions. We have incorporated the suggested change (section 7, page 5).

1. Please include information regarding the importance of assisting trans men in their self-affirmative journey, the importance of interacting with trans community groups or activists.

Authors’ response: Thank you for your suggestions. We have incorporated the suggested change in section 10, page 7.

1. Please include information on the importance of providing medical training in Sri Lanka that includes topics on transgender health.

Authors’ response: Thank you for your suggestions. We have incorporated the suggested change in section 11, page 7.

Reviewer: 2

Comments to the Author

This paper looks at FtM transgender people in a South Asian context and provides new information mainly in relation to the new geographic location. The literature review is the basis of a strong paper with some good information from US sources in the main, which should be augmented from other Asia-pacific sources where possible. 

On binary and non-binary identity, it may be important to note that studies have shown that most FtM transgender (transmen) see themselves as 'men' or 'male', and the most common preferred surgery is chest surgery [Jones, T., del Pozo De Bolger, A., Dunne, T., Lykins, A. and Hawkes, G. (2015). Female-to-Male (FtM) Transgender People's Experiences in Australia. Cham, Switzerland: Springer. ISBN 978-3-319-13829-9]. However, it is also worth noting the shift in identity over time. Now, half of young transgender people identify as non-binary [Smith et al. 2014. From Blues to Rainbows. Melbourne: ARCSHS].

Authors’ response: Thank you for your suggestions. We have incorporated the suggested sentences and the references. (Sections 4.1, page 3 and Section 6, page 5)

On cancer, there has been some research on combatting dysphoria that occurs in high rates in the interactions during cancer care, that is important to note. It would be important to establish that cancer care can be delivered in discriminatory ways or withheld by some doctors for these patients. Around page 3 line 103 it would be useful to then note the call for FtM transgender patients (transmen) to be treated with less discrimination - for example to be asked which words they prefer to use for their body parts, or to use words that are not gendered like chest and genitals (rather than for example, breast tissue or vagina). Some references:

Riggs, D., & Due, C. (2013). Gender Identity Australia: The healthcare experiences of people whose gender identity differs from that expected of their natally assigned sex. Adelaide: School of Social and Policy Studies, Flinders University.

Schulz, S. L., Kamens, S. R., Robbins, B. D., & Flanagan, E. H. (2018). The Informed Consent Model of Transgender Care: An Alternative to the Diagnosis of Gender Dysphoria. Journal of Humanistic Psychology, 58(1), 72-92.  

Silverberg, M. J., Nash, R., Becerra-Culqui, T. A., Cromwell, L., Getahun, D., Hunkeler, E., . . . Goodman, M. (2017). Cohort study of cancer risk among insured transgender people. Annals of Epidemiology, 27(8), 499-501.

Authors’ response: Thank you for your valuable suggestions. We have incorporated the suggested changes and the references in section 3 page 3.

These studies also noted improvements in FtM transgender people after some form of gender affirmation, however affirmations could vary from social, to medical for example. It may be worth emphasising the differences in options (that some prefer only social changes) a little more, and that this may or may not align with binary and non-binary identities... this is a little unclear in the piece as it currently stands. Otherwise, a great piece overall!

Authors’ response: Thank you for your valuable suggestions. We have revised the manuscript based on your comments Section 1, page 2.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Thanks to the changes implemented the manuscript is now, I believe, 
sufficiently improved to warrant publication in Sexes.

Best wishes.