Healthcare Access for Transgender Women in Malaysia: A Narrative Review of Barriers and Enabling Factors

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for inviting me to review this interesting and well written paper. Please see the attached document for my detailed comments.

Comments for author File: Comments.pdf

Author Response

 

Author's response to Reviewer 1 comments:

Thank you very much for taking the time to review the manuscript. We have made our best effort to implement the suggested changes.

Major Comments:

Comment 1: Please describe how the search was conducted and what you mean by "relevant non-indexed" materials.

Response: This has been amended by adding details Line 83-94 as follows:

Initial searches were done in PubMed, Scopus, Web of Science, PsycINFO, and CINAHL. Additional sources were identified through Google Scholar and grey literature repositories, including organizational reports from SEED Foundation, PT Foundation, Malaysian AIDS Council, and UNAIDS. The search aimed to capture peer-reviewed articles and relevant non-indexed materials addressing health care access and utilization among transgender women in Malaysia. (("Transgender Persons"[MeSH] OR "transgender women" OR "transwomen") AND ("Health Services Accessibility"[MeSH] OR "healthcare access" OR "Health Services"[MeSH] OR "Health Care Utilization" OR "Health Services Utilization") AND ("Patient Acceptance of Health Care"[MeSH] OR "facilitators" OR "enablers" OR "healthcare-seeking behavior" OR "barriers and facilitators") AND ("Malaysia"[MeSH] OR Malaysia)) NOT "Men who have sex with men"[MeSH].

Comment 2: I think that it is important to know about the positionality of the authors. Why are they interested in this topic? If it is not safe for them to declare their positionality because of attitudes in Malaysia or other reasons, this should be stated. I found the positionality statement at the end of the paper, but I would like to see it included in the main body of the paper and to include all three authors.

Response: We would like to keep the positionality statement at the end of the paper, following a more standard format for reporting.

Minor Comments:

Comment 3: Citation formatting is inconsistent throughout.

Response: The citation format has been corrected and made consistent

Comment 4: Line 115. Please define all abbreviations at first use (MSM). Also, MSM is already plural and doesn't need an s.

Line 122. Please define ART.

Response: This has been corrected

Line 150. Please elaborate on how religious issues affect mental healthcare.

Response: the sentence has been modified (Line 173-175) as follows : “Transgender individuals in Malaysia face significant mental health challenges due to various barriers in accessing appropriate services, including exposure to minority stressors, concerns about confidentiality, and conflicts arising from religious beliefs [19,22,48].”

 

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Overall Recommendation: Reconsider after Major Revision – The topic is important and within scope, but substantial revisions are required to improve the manuscript’s clarity, methodological transparency, and integration of recent literature. Specific concerns and suggestions are detailed below.

 

Originality

The manuscript covers an under-researched population (transgender women in Malaysia) and synthesizes information on barriers and facilitators to healthcare. While this country-specific focus is valuable and novel in compiling disparate sources, the content largely confirms known challenges (legal barriers, stigma, lack of training) that have been reported in other contexts. The review does not propose new theories or data, but rather narratively summarizes existing studies and reports. To enhance originality, the authors should clarify what new insights this narrative review provides beyond prior studies (e.g. comparing multiple healthcare domains in one paper, highlighting unique cultural/legal nuances in Malaysia). Framing the findings in the context of broader sex and gender scholarship (such as minority stress theory or intersectionality) could also underscore the manuscript’s unique contribution. Currently, the originality is acceptable but not standout – it fills a gap by focusing on Malaysia, yet the authors should better distinguish their review from earlier works (for example, by Barmania (2017) or Gibson et al. (2016) which are cited, and the Tan et al. (2021) scoping review). Emphasizing any new perspectives or under-recognized issues identified (for instance, the inclusion of oral health issues is an interesting addition) will strengthen the perception of originality.

 

Clarity of Presentation

The manuscript is generally readable and organized into logical sections (barriers in various healthcare domains, then enabling factors). The writing style is scientific and mostly clear. Definitions of key concepts like “healthcare access” vs “utilization” are provided, which is helpful. However, there are areas where clarity and structure could be improved. The section on “Barriers” combines multiple sub-topics (primary care, sexual health, oral health, mental health) under a single heading. For better readability, consider delineating these sub-sections more distinctly – for example, use subheadings or numbered sub-sections for each domain (2.1 Primary Care, 2.2 Sexual Health, etc.) rather than just bold text in-line. This will guide the reader through the different domains more clearly. Moreover, some paragraphs are quite dense with information and multiple citations. Breaking up long paragraphs and ensuring each has a clear topic sentence would improve flow. There are minor grammatical issues and typos that need attention for clarity. For instance, in the Table 1 enablers column, the phrase “Constance community engagement” appears – this seems to be a typo (perhaps intended to be “constant community engagement”). Likewise, ensure consistent terminology (the manuscript appropriately uses “transgender women” throughout; avoid abbreviating to “transwomen” to maintain formality). The narrative in some places could be tightened – e.g. the sentence spanning lines 260–262 (“Creating an entry point to increased access to healthcare services, along with capacity building…”), is overly abstract and wordy. Phrases like “creating an entry point” and “in this direction” lack specificity, and the sentence could be made clearer and more impactful by rephrasing with more direct language and concrete terms. Overall, the authors should perform a thorough copy-edit for language accuracy and coherence. The inclusion of Table 1 summarizing barriers and enablers is a strong point for clarity – it provides a quick reference. Make sure that the table is formatted correctly (each bullet in a separate line, and spelling errors corrected). With these improvements in structure and proofreading, the presentation will be much clearer.

 

Methodology

As a narrative review, the paper lacks a detailed methods section, which raises concerns about the rigor and reproducibility of the literature search. The authors state that a “broad narrative approach was used” and that the search aimed to capture peer-reviewed articles and relevant non-indexed materials on this topic. However, the manuscript does not specify how sources were identified (e.g. which databases were searched, what keywords were used, any inclusion/exclusion criteria, or time frame of the literature). This transparency is important even for a narrative review to establish credibility. I recommend the authors add a brief description of their search strategy and selection process. For example: which electronic databases (PubMed, Scopus, etc.) or local journals were consulted? Did the authors include only English-language sources? How were non-indexed materials (e.g. NGO reports, policy documents) found and chosen? Providing this information will help readers trust that the review is comprehensive and not cherry-picked. In its current form, the methodology appears anecdotal – it’s unclear if all relevant literature was captured or just a convenient sample. For instance, the authors cite many appropriate sources, but it’s possible some important recent studies were missed (see literature suggestions below). Clarifying the methodology will also allow others to update or replicate the review in the future. Furthermore, the authors should acknowledge the limitations of a narrative (non-systematic) review: namely, that it may not capture every study and could be subject to selection bias. A short statement on this, perhaps in the Introduction or Conclusion, would demonstrate methodological reflexivity. If any particular inclusion criteria were applied (e.g. focusing on the last 10–15 years of research), state that explicitly. Overall, significant improvement in methodological transparency is needed for scientific soundness.

 

Scientific Soundness

The content of the review is generally scientifically sound in that it aligns with findings from the cited literature and the conclusions drawn are reasonable given the evidence. The authors correctly identify and discuss major barriers (legal environment, stigma/discrimination, lack of provider training, etc.) and enabling factors (transgender-inclusive training, policy reforms, community engagement, technology-based interventions) that are well-supported by existing studies and reports. Each claim is accompanied by citations, which is good. I did not find instances of gross misinterpretation of sources; the authors appear to fairly summarize the referenced studies. However, there are a few areas to address to ensure robustness and scholarly thoroughness:

1. Depth of Analysis: In some sections, the manuscript reads as an enumeration of findings from various sources without deeper critical analysis. For example, multiple studies are cited back-to-back to list barriers (lines 95–111). While this is informative, the authors could improve scientific rigor by synthesizing these findings – are there any conflicting reports in the literature about barriers or any consensus on which barrier is most significant? A more analytic tone (beyond simple summary) would strengthen the review’s impact. For instance, the discussion could highlight how legal barriers (like lack of gender recognition) interact with social stigma to compound healthcare avoidance, drawing on theory or multi-country comparisons.
2. Support for Generalizations: Be cautious about making broad generalizations from single studies. In a few places, the text implies a general condition based largely on one source. For example, it is stated that “transgender women in Malaysia reportedly rely on self-medication … and some resort to illegal gender-affirming procedures, which in many cases lead to poor health consequences”. This important point is backed by references, but it would benefit from clearer framing that this is based on observed trends in studies (some of which may have small sample sizes). Wherever possible, quantify or specify the evidence (e.g. “in a 2021 mixed-methods study, X% of trans women reported using hormones without medical supervision”). Similarly, the statement that “transgender stigma, fear, and personal shame… play an important role in physicians’ discrimination” is intriguing – if this is derived from reference 34 (Vijay et al. 2018), perhaps clarify that this was a finding about physician intent in Kuala Lumpur. In short, ensure that each broad statement is traceable to solid evidence, and nuance the language when evidence is suggestive but not definitive (e.g. using “may lead to…” or “some transgender women have been reported to…”).
3. Enabling Factors Evidence: The section on enablers is forward-looking and largely based on logical reasoning or analogies to known interventions (e.g. STI-friendly clinics, community organizations like Tangerine Clinic, PrEP rollout). This is appropriate, but to be scientifically sound the authors should indicate where these enablers are proven versus proposed. For instance, the manuscript notes that follow-up data on the success of STI-friendly clinics in Malaysia is “sparse” – which is an important caveat. Likewise, when citing examples like Tangerine Clinic in Thailand or LoveYourself in the Philippines, it would strengthen the review to mention any documented outcomes or improvements from those initiatives (if available in literature). If such data aren’t available, that’s fine, but clarify that these are promising examples rather than fully evaluated solutions. This will prevent overstatement of unproven interventions.
4. Literature Coverage: Scientifically, the manuscript would be stronger if it incorporated more recent studies and global perspectives (see the Literature Suggestions section). The current reference list is extensive and includes up-to-2025 sources, which is excellent. However, a few key recent peer-reviewed works on transgender health (especially in low- and middle-income countries) are not cited. Including them will ensure the review is up-to-date and comprehensive. Notably, I did not see references to the Lancet’s 2016 transgender health series or other recent systematic reviews of transgender health disparities. Integrating insights from such works (even if global) can provide a stronger evidence base or conceptual framework for the issues discussed (for example, framing the health disparities of Malaysian transgender women in the context of global transgender health burdens).

Overall, the scientific soundness is acceptable, but the authors should aim to deepen their analysis and ensure all claims are well-supported and nuanced. Addressing the points above will improve the manuscript’s credibility and scholarly value.

 

Presentation & Structure

The manuscript is well-organized overall. It progresses from an introduction (setting context of Malaysian healthcare and transgender marginalization) into distinct sections on barriers (by healthcare domain) and then into enablers, concluding with a summary and recommendations. This structure is logical and helps readers follow the narrative. The inclusion of Table 1 summarizing barriers vs. enablers is a strong point – it provides a clear, concise overview. A few suggestions to further improve presentation:

1. Section Headings: As noted under Clarity, consider using explicit sub-section headings for each healthcare domain in the barriers section (and similarly for each major enabling factor, if possible). In the current format, the headings like “Primary healthcare:” or “Mental healthcare:” appear inline. Converting these to actual sub-headings (with numbering or at least bold lines) would make the document easier to navigate. This is a formatting refinement that the journal’s style might allow and would benefit readers, especially when quickly scanning for specific content (e.g., a reader interested mainly in mental health can find that section easily).
2. Writing Style: Ensure consistency in tone. Most of the paper is written in an objective, academic tone, which is appropriate. Phrases like “This only deepens the barriers…” (line 109-111) might be better phrased more formally (“This further deepens the barriers…”). Also, avoid casual terms – for example, use “individuals” or “people” rather than “persons” for smoother reading (unless quoting an official title like “Human Rights Commission of Malaysia”). Overall, just minor polishing of language is needed; the tone is already scientific.
3. Length and Redundancy: The manuscript is somewhat lengthy, but given it’s a narrative review covering multiple facets, the length is acceptable. Just ensure every paragraph is necessary and adds value – there were a couple of instances that felt a bit repetitive. For example, the emphasis on UHC providing access but transgender needs not met is made in the Introduction and again later; make sure each mention adds new context. The conclusion could be more succinct – it currently restates many points. Try to focus the conclusion on the implications and next steps (e.g., the need for policy alignment and the importance of the findings for practitioners and researchers), rather than recapping all findings in detail.
4. Figures/Tables: Apart from Table 1, there are no figures. A suggestion (optional): a conceptual figure or model illustrating the intersection of barriers might be useful (for instance, a diagram showing individual, interpersonal, and structural level barriers and how they lead to outcomes). This is not strictly necessary, but in a journal on sexes, a figure highlighting the socio-ecological model of transgender health in Malaysia could be appealing. The authors might consider this if feasible, drawing on the content they already have.

Finally, the reflexivity and positionality statement is a noteworthy inclusion in terms of presentation and ethics. It is commendable that the authors identified their backgrounds and took steps to remain unbiased. Make sure this statement follows journal guidelines (its placement at the end before references is fine here). It adds transparency and is appropriate given the sensitive subject matter.

 

Literature and References

The reference list is extensive and generally well-chosen, covering a mix of local studies, global research, and reports. Citations are up-to-date through 2025, which is excellent. There is a healthy number of Malaysian-specific sources (e.g., SUHAKAM 2019, local qualitative studies, national reports) alongside international literature. One concern is the reliance on self-citations: the authors cite several of their own works (Telang et al. 2025a; Telang et al. 2025b; Rashid et al. 2023; Rashid et al. 2021, etc.). While these are certainly relevant (and it’s natural to cite one’s related research), the authors should ensure they are not overweighting their interpretation based on their own findings.

In a review, it’s important to maintain a balanced perspective. I encourage adding additional independent references to complement the authors’ studies, especially if those external studies report similar findings – this will show that observations are not isolated to the authors’ work. I provide a list of suggested recent references below that could strengthen the manuscript. Each suggested work is from the last 5–10 years and relates to transgender healthcare access or outcomes. Integrating these will both update and broaden the review’s scholarly foundation.

Suggested Additional Literature for Inclusion:

The authors should consider citing and discussing the following peer-reviewed works to enhance the manuscript’s depth and currency:

1. Coleman, E. et al. (2022). “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” International Journal of Transgender Health 23(Suppl 1): S1-S259. – These recently updated international guidelines (WPATH SOC-8) outline best practices for gender-affirming care. While this is a very clinically oriented document, citing it could be useful when discussing the lack of gender-affirming services in Malaysia. It provides authoritative support for what components should ideally be available (e.g., hormone therapy, surgical aftercare, mental health support) and thus highlights the gap in the Malaysian healthcare system where such services are “absent from routine public healthcare,” as you note. Referring to SOC-8 could strengthen your call for integrating trans-specific health needs into national priorities and for healthcare policy reform.
2. Ghosh, A. (2021). “The Politics of Alignment and the 'Quiet Transgender Revolution' in Fortune 500 Corporations.” Socio-Economic Review, 19(3), 1095–1125 – This study investigates how U.S. Fortune 500 companies adopted transgender-inclusive healthcare benefits by aligning LGBTQ advocacy with corporate values through non-confrontational strategies, particularly leveraging the Human Rights Campaign’s Corporate Equality Index. This “quiet revolution” succeeded not through protest, but via institutional alignment—demonstrating how transgender inclusion can advance within rigid systems when change appeals to organizational self-interest and legitimacy concerns. This insight has direct relevance to the Malaysian healthcare context addressed in the manuscript: it suggests that reforming public healthcare to support transgender women may depend on similar alignment between public health goals, institutional prestige, and sociocultural acceptability. Referencing this study would strengthen the manuscript’s arguments on overcoming structural inertia and developing enabling policies through strategic, context-aware engagement with institutions.
3. Ghosh, A. (2025). “Cultural Competence in Transgender Healthcare.” (Book chapter in Advancing Equity: Health, Rights, and Representation in LGBTQ+ Communities). – A very recent piece emphasizing the need for cultural competence among healthcare providers serving transgender patients. Including this reference would back up the manuscript’s section on “Inclusivity training for healthcare workers” as an enabling factor. It provides contemporary evidence and arguments that improving providers’ knowledge and attitudes (through education, policy reform, and community collaboration) can reduce systemic inequities – directly resonating with your recommendations for training and cultural safety..
4. Ghosh, A. (2020). “The Global LGBTQ Workplace Equality Movement.” In The Wiley Blackwell Companion to Sexuality Studies, pp. 445–463. – It explores how LGBTQ equality movements achieve progress differently across global contexts, emphasizing the need for localized strategies that reflect sociopolitical and religious conditions. In Malaysia, Ghosh notes that high structural stigma and religious condemnation force activists to prioritize instrumental goals like legal protections over expressive goals such as cultural acceptance. This distinction closely parallels the manuscript’s discussion on healthcare for transgender women, where institutional exclusion (e.g., lack of gender recognition, provider discrimination) impedes access. Citing this work would deepen the manuscript’s analytical grounding by framing Malaysia’s healthcare challenges within a broader global framework, reinforcing that targeted policy reform—tailored to local constraints—is essential for effective transgender inclusion in conservative societies.
5. Hughto, J.M.W., Reisner, S.L., & Pachankis, J. (2015). “Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions,” Social Science & Medicine 147:222-231. – This review conceptualizes how multi-level stigma harms transgender health. Including it would provide a theoretical framework for several points in your manuscript – for example, linking interpersonal discrimination and structural stigma (laws, policies) to healthcare avoidance and mental health issues. It complements references like Poteat et al. 2013 that you cited, but is more recent and comprehensive in scope. It can strengthen the argument that stigma is a root cause of the healthcare access barriers noted in Malaysia, thereby justifying the need for interventions like provider training and policy reform.
6. Maoto, M. & Davis, B. (2024). “Breaking barriers: How transwomen meet their healthcare needs,” African Journal of Primary Health Care & Family Medicine 16(1):4598. – A recent qualitative study from South Africa (another context of the Global South) which explored transgender women’s experiences with mainstream healthcare and their alternative strategies to obtain care. The findings mirror many issues raised in your review: widespread discrimination in health facilities, resorting to self-medication or community networks, etc. Citing this study would provide a comparative perspective, showing that many barriers faced by Malaysian trans women (stigma, lack of access to hormones, etc.) are also documented in other regions. This can underscore the significance of your recommendations — for instance, the need for inclusive health management is echoed by Maoto & Davis’s conclusion that equitable and inclusive healthcare is urgently needed for transwomen. Including it also broadens the manuscript’s appeal to an international readership by connecting local findings to global patterns in transgender healthcare.
7. Winter, S. et al. (2016). “Transgender people: health at the margins of society,” The Lancet 388(10042):390-400. – Part of The Lancet’s series on transgender health, this article examines global health disparities faced by transgender people, especially in Asia-Pacific. Citing Winter et al. would situate the Malaysian findings in a global context – for instance, reinforcing how stigma and exclusion lead to poor health outcomes worldwide. It can bolster your introduction or conclusion when arguing that the issues in Malaysia reflect broader patterns that require rights-based approaches (the Lancet piece strongly advocates that transgender rights are critical for health).

The above references are suggestions to improve the manuscript’s scholarly grounding. Including them will demonstrate engagement with up-to-date literature and situate the Malaysian context within the broader field of transgender health and sexuality studies.

 

To conclude. let me first acknowledge that this review addresses a vital topic. The manuscript is well-intentioned and contains valuable information for both healthcare providers and researchers. The multidisciplinary consideration – covering primary care, sexual health (HIV/STI), oral health, and mental health – is a strong point; it recognizes that transgender women’s healthcare needs are holistic. The inclusion of Malaysian data and reports (e.g. SUHAKAM, Ministry of Health reports, local studies) gives the review local relevance and practical significance. The discussion of enabling factors is forward-looking and offers constructive ideas that policymakers and community organizations could act upon. The reflexivity statement demonstrates ethical care. These strengths mean that, after revision, the paper could make a meaningful contribution.

However, to reach that point, the manuscript needs major revisions in the areas noted above. I summarize the most critically needed changes here:

1. Improve methodological transparency. Clearly describe how the literature was gathered. Even if it is not a systematic review, provide enough detail so readers trust that this narrative review is comprehensive and not biased. Outline the scope (years considered, types of sources, any focus on certain study designs or populations). This will significantly boost the paper’s credibility.
2. Enhance clarity and organization. Rework the structure to ensure sub-sections are well delineated. Edit language for conciseness and fix any grammatical errors. These changes will make the manuscript more reader-friendly. A well-structured paper is particularly important for an interdisciplinary audience (some readers from social sciences, some from health sciences), so clarity is key.
3. Deepen the analysis. Go beyond summarizing facts by adding interpretive commentary. For example, after listing various barriers, synthesize them: “Taken together, these studies suggest that beyond individual bias, institutional policies (like gendered wards and legal ID) systematically marginalize transgender women, aligning with the concept of structural stigma.” Similarly, in the enablers section, acknowledge feasibility or evidence level: “While initiatives like STI-friendly clinics show promise, their long-term efficacy remains to be evaluated, indicating a need for implementation research.” Adding such analysis will show the authors’ critical engagement with the material, not just a descriptive account.
4. Incorporate additional pertinent literature. As detailed in the list above, there are several recent works that would strengthen your arguments. Works on cultural competence in transgender healthcare, adoption of transition-related health benefits, and global inclusion of transgender persons can provide sociological depth on transgender issues in contexts like Malaysia. The global health studies (Winter et al., Poteat et al., etc.) can reinforce the significance of your observations. These will guard against the appearance of any gaps in knowledge. It will also ensure the manuscript resonates with the sex and sexualities studies field by connecting to broader scholarly conversations.
5. Address ethical considerations. Although this is a review, you have handled ethical aspects well by disclosing authors’ positionality and stating lack of conflicts. One additional point: be mindful of any potential self-plagiarism. If text from your own prior publications (such as the 2025 studies you cite) was reused, it must be rephrased or quoted. From my reading, the text seems original (I did not detect obvious overlap with other texts), but it’s worth double-checking to avoid any inadvertent text duplication. Since you cite your previous studies, you likely have paraphrased appropriately; just ensure no lengthy passages are copied verbatim. The journal may run a plagiarism check, so it’s best if you preemptively ensure originality of phrasing.

Given these required revisions, I recommend “Reconsider after Major Revision.” The paper has potential and is on a worthwhile topic, but it is not yet ready for publication in its current form. I encourage the authors to revise thoroughly, as I believe the manuscript could be much improved with the above changes. The additional context and clarity will make it a more impactful resource on transgender healthcare in Malaysia, bridging public health and sexualities research in a meaningful way.

Comments on the Quality of English Language

The manuscript is generally well-written, with a clear academic tone and appropriate terminology. However, several sections would benefit from careful proofreading to improve sentence clarity, grammar, and conciseness. In some instances, the narrative becomes wordy or vague due to abstract phrasing and passive constructions (e.g., “creating an entry point,” “only a few methods have been put in place”). Paragraphs can also be dense, with long sentences that hinder readability. Attention to parallel structure, active voice, and consistency in terminology (e.g., “transgender women” vs. shorthand terms) would enhance the overall fluency and precision of the text. While the English is intelligible throughout, a thorough copy-edit is recommended to bring the language up to the standards of a high-impact academic journal.

Author Response

 

Author's response to Reviewer 2 comments:

We would like to thank the reviewer for the comprehensive and detailed review provided along with the valuable suggestions. We have made every effort to amend the manuscript based on your suggestions.

Comment 1:

Overall Recommendation: Reconsider after Major Revision – The topic is important and within scope, but substantial revisions are required to improve the manuscript’s clarity, methodological transparency, and integration of recent literature. Specific concerns and suggestions are detailed below.

 Originality

The manuscript covers an under-researched population (transgender women in Malaysia) and synthesizes information on barriers and facilitators to healthcare. While this country-specific focus is valuable and novel in compiling disparate sources, the content largely confirms known challenges (legal barriers, stigma, lack of training) that have been reported in other contexts. The review does not propose new theories or data, but rather narratively summarizes existing studies and reports. To enhance originality, the authors should clarify what new insights this narrative review provides beyond prior studies (e.g. comparing multiple healthcare domains in one paper, highlighting unique cultural/legal nuances in Malaysia). Framing the findings in the context of broader sex and gender scholarship (such as minority stress theory or intersectionality) could also underscore the manuscript’s unique contribution. Currently, the originality is acceptable but not standout – it fills a gap by focusing on Malaysia, yet the authors should better distinguish their review from earlier works (for example, by Barmania (2017) or Gibson et al. (2016) which are cited, and the Tan et al. (2021) scoping review). Emphasizing any new perspectives or under-recognized issues identified (for instance, the inclusion of oral health issues is an interesting addition) will strengthen the perception of originality.

 Response: We thank the reviewer for this insightful and constructive comment. In response, we have revised the manuscript to articulate the novel contributions of this narrative review more clearly. The under-recognized issue that we have emphasized is oral healthcare barriers. The review also offers an interesting perspective on the enabling factors tailored to the current healthcare context in Malaysia.

Comment 2:

Clarity of Presentation

The manuscript is generally readable and organized into logical sections (barriers in various healthcare domains, then enabling factors). The writing style is scientific and mostly clear. Definitions of key concepts like “healthcare access” vs “utilization” are provided, which is helpful. However, there are areas where clarity and structure could be improved. The section on “Barriers” combines multiple sub-topics (primary care, sexual health, oral health, mental health) under a single heading. For better readability, consider delineating these sub-sections more distinctly – for example, use subheadings or numbered sub-sections for each domain (2.1 Primary Care, 2.2 Sexual Health, etc.) rather than just bold text in-line. This will guide the reader through the different domains more clearly. Moreover, some paragraphs are quite dense with information and multiple citations. Breaking up long paragraphs and ensuring each has a clear topic sentence would improve flow.

There are minor grammatical issues and typos that need attention for clarity. For instance, in the Table 1 enablers column, the phrase “Constance community engagement” appears – this seems to be a typo (perhaps intended to be “constant community engagement”). Likewise, ensure consistent terminology (the manuscript appropriately uses “transgender women” throughout; avoid abbreviating to “transwomen” to maintain formality). The narrative in some places could be tightened – e.g. the sentence spanning lines 260–262 (“Creating an entry point to increased access to healthcare services, along with capacity building…”), is overly abstract and wordy. Phrases like “creating an entry point” and “in this direction” lack specificity, and the sentence could be made clearer and more impactful by rephrasing with more direct language and concrete terms. Overall, the authors should perform a thorough copy-edit for language accuracy and coherence. The inclusion of Table 1 summarizing barriers and enablers is a strong point for clarity – it provides a quick reference. Make sure that the table is formatted correctly (each bullet in a separate line, and spelling errors corrected). With these improvements in structure and proofreading, the presentation will be much clearer.

 Response:

• Subsections have been numbered.
• Long paragraphs have been broken into smaller ones throughout the document.
• Typographic error in table 1 has been corrected and formatted into figure 1
• “Transgender women” terminology has been used consistently throughout the document.
• Language accuracy and coherence have been rechecked

Comment 3:

Methodology

As a narrative review, the paper lacks a detailed methods section, which raises concerns about the rigor and reproducibility of the literature search. The authors state that a “broad narrative approach was used” and that the search aimed to capture peer-reviewed articles and relevant non-indexed materials on this topic. However, the manuscript does not specify how sources were identified (e.g. which databases were searched, what keywords were used, any inclusion/exclusion criteria, or time frame of the literature). This transparency is important even for a narrative review to establish credibility. I recommend the authors add a brief description of their search strategy and selection process. For example: which electronic databases (PubMed, Scopus, etc.) or local journals were consulted? Did the authors include only English-language sources? How were non-indexed materials (e.g. NGO reports, policy documents) found and chosen? Providing this information will help readers trust that the review is comprehensive and not cherry-picked. In its current form, the methodology appears anecdotal – it’s unclear if all relevant literature was captured or just a convenient sample. For instance, the authors cite many appropriate sources, but it’s possible some important recent studies were missed (see literature suggestions below). Clarifying the methodology will also allow others to update or replicate the review in the future.

Furthermore, the authors should acknowledge the limitations of a narrative (non-systematic) review: namely, that it may not capture every study and could be subject to selection bias. A short statement on this, perhaps in the Introduction or Conclusion, would demonstrate methodological reflexivity. If any particular inclusion criteria were applied (e.g. focusing on the last 10–15 years of research), state that explicitly. Overall, significant improvement in methodological transparency is needed for scientific soundness.

 Response:

• Details have been added to methodology of the narrative review, including search terms and making it more transparent
• This has been amended by adding details Line 83-94 as follows:

Initial searches were done in PubMed, Scopus, Web of Science, PsycINFO, and CINAHL. Additional sources were identified through Google Scholar and grey literature repositories, including organizational reports from SEED Foundation, PT Foundation, Malaysian AIDS Council, and UNAIDS. The search aimed to capture peer-reviewed articles and relevant non-indexed materials addressing health care access and utilization among transgender women in Malaysia. (("Transgender Persons"[MeSH] OR "transgender women" OR "transwomen") AND ("Health Services Accessibility"[MeSH] OR "healthcare access" OR "Health Services"[MeSH] OR "Health Care Utilization" OR "Health Services Utilization") AND ("Patient Acceptance of Health Care"[MeSH] OR "facilitators" OR "enablers" OR "healthcare-seeking behavior" OR "barriers and facilitators") AND ("Malaysia"[MeSH] OR Malaysia)) NOT "Men who have sex with men"[MeSH].

• (Line 18-327) The conclusion has been strengthened by adding the following statement: “This narrative review recognizes that transgender women’s healthcare needs are comprehensive and provides insights into various healthcare areas impacting transgender women in Malaysia. Although narrative reviews might not capture every study and can be subject to selection bias, the authors believe this review successfully focuses on the overall health of transgender women and identifies underrecognized issues, such as oral health care utilization. Given the socio-legal context in Malaysia surrounding transgender rights, this narrative review provides essential information for advocating transgender healthcare. A summary of the findings from the review has been displayed while situating the Malaysian context within the broader global landscape of transgender health by utilizing the socio-ecological model [76-78] .”

Comment 4:

Scientific Soundness

The content of the review is generally scientifically sound in that it aligns with findings from the cited literature and the conclusions drawn are reasonable given the evidence. The authors correctly identify and discuss major barriers (legal environment, stigma/discrimination, lack of provider training, etc.) and enabling factors (transgender-inclusive training, policy reforms, community engagement, technology-based interventions) that are well-supported by existing studies and reports. Each claim is accompanied by citations, which is good. I did not find instances of gross misinterpretation of sources; the authors appear to fairly summarize the referenced studies. However, there are a few areas to address to ensure robustness and scholarly thoroughness:

1. Depth of Analysis: In some sections, the manuscript reads as an enumeration of findings from various sources without deeper critical analysis. For example, multiple studies are cited back-to-back to list barriers (lines 95–111). While this is informative, the authors could improve scientific rigor by synthesizing these findings – are there any conflicting reports in the literature about barriers or any consensus on which barrier is most significant? A more analytic tone (beyond simple summary) would strengthen the review’s impact. For instance, the discussion could highlight how legal barriers (like lack of gender recognition) interact with social stigma to compound healthcare avoidance, drawing on theory or multi-country comparisons.

 

Response: (Line 98-107) The paragraph has been revised to deepen the analysis, the following statements have been added: “The healthcare needs of transgender women might not be fully addressed, even though health facilities are accessible to everyone through Malaysia's UHC system. [17].  Moreover, inadequacies in addressing transgender-specific health issues are com-pounded by policies and laws that prohibit changing one's gender for any reason [26]. Laws against ‘cross-dressing’ and ‘men posing as women’ particularly affect transgender women, making them hesitant to seek healthcare for the fear of criminal-ization or further discrimination [27]. An example of such weaknesses in healthcare settings is the situation where transgender women are placed in male wards when hospitalized [10]. Rejections of health insurance claims due to discrepancies in physi-cal appearance and gender marker on identification cards have also been reported [27]. “

 

1. Support for Generalizations: Be cautious about making broad generalizations from single studies. In a few places, the text implies a general condition based largely on one source. For example, it is stated that “transgender women in Malaysia reportedly rely on self-medication … and some resort to illegal gender-affirming procedures, which in many cases lead to poor health consequences”. This important point is backed by references, but it would benefit from clearer framing that this is based on observed trends in studies (some of which may have small sample sizes). Wherever possible, quantify or specify the evidence (e.g. “in a 2021 mixed-methods study, X% of trans women reported using hormones without medical supervision”). Similarly, the statement that “transgender stigma, fear, and personal shame… play an important role in physicians’ discrimination” is intriguing – if this is derived from reference 34 (Vijay et al. 2018), perhaps clarify that this was a finding about physician intent in Kuala Lumpur. In short, ensure that each broad statement is traceable to solid evidence, and nuance the language when evidence is suggestive but not definitive (e.g. using “may lead to…” or “some transgender women have been reported to…”).

 

Response: (Line 108-116) “The lack of provisions for gender-affirming procedures such as feminizing hor-mone prescriptions, surgical options, and aftercare as part of routine services in public healthcare settings contributes to these inadequacies in healthcare [11,17,26,27].  A study conducted on transgender women in 2018 in Kuantan revealed that 94.2% of the participants purchased their hormones over the counter from local pharmacies [29]. A similar report in 2021 on the West Coast of Peninsular Malaysia found that a signifi-cant proportion of transgender women (71%) resort to self-medication during their transition process, predominantly involving the use of unregulated and unsupervised hormone treatments, including illegal gender-affirming procedures, which, in many cases, lead to overall poor health consequences [30].”  

 

1. Enabling Factors Evidence: The section on enablers is forward-looking and largely based on logical reasoning or analogies to known interventions (e.g. STI-friendly clinics, community organizations like Tangerine Clinic, PrEP rollout). This is appropriate, but to be scientifically sound the authors should indicate where these enablers are proven versus proposed. For instance, the manuscript notes that follow-up data on the success of STI-friendly clinics in Malaysia is “sparse” – which is an important caveat. Likewise, when citing examples like Tangerine Clinic in Thailand or LoveYourself in the Philippines, it would strengthen the review to mention any documented outcomes or improvements from those initiatives (if available in literature). If such data aren’t available, that’s fine, but clarify that these are promising examples rather than fully evaluated solutions. This will prevent overstatement of unproven interventions.

 

Response: (Line 260-268) “Creating supportive communities for transgender women is essential for enhancing their physical and mental health. Promising examples of transgender-led community-based organizations in the neighboring states include the Tangerine clinic in Thailand [59] and Love Yourself [60] in the Philippines. These are sustainable models of clinics that provide access to comprehensive and quality health care services through the involvement of members of the transgender community who play a pivotal role in running the clinic [59,61,62]. The model trains transgender lay providers to engage and retain patients in primary care by providing counselling services and encouraging the uptake of transgender specific services like gender affirming care in the clinic [61,63].”  

 

1. Literature Coverage: Scientifically, the manuscript would be stronger if it incorporated more recent studies and global perspectives (see the Literature Suggestions section). The current reference list is extensive and includes up-to-2025 sources, which is excellent. However, a few key recent peer-reviewed works on transgender health (especially in low- and middle-income countries) are not cited. Including them will ensure the review is up-to-date and comprehensive. Notably, I did not see references to the Lancet’s 2016 transgender health series or other recent systematic reviews of transgender health disparities. Integrating insights from such works (even if global) can provide a stronger evidence base or conceptual framework for the issues discussed (for example, framing the health disparities of Malaysian transgender women in the context of global transgender health burdens).

Overall, the scientific soundness is acceptable, but the authors should aim to deepen their analysis and ensure all claims are well-supported and nuanced. Addressing the points above will improve the manuscript’s credibility and scholarly value.

Response: (Line 327, 330-332)The reference of “Lancet 2016” has been used in the conclusion: “Repeated systematic exposure to social stressors, such as societal exclusion and legal issues, is suggested to cause inequality in health care, contributing to disease and disability among sexual and gender minorities, including transgender individuals.”

 

Presentation & Structure

The manuscript is well-organized overall. It progresses from an introduction (setting context of Malaysian healthcare and transgender marginalization) into distinct sections on barriers (by healthcare domain) and then into enablers, concluding with a summary and recommendations. This structure is logical and helps readers follow the narrative. The inclusion of Table 1 summarizing barriers vs. enablers is a strong point – it provides a clear, concise overview. A few suggestions to further improve presentation:

1. Section Headings: As noted under Clarity, consider using explicit sub-section headings for each healthcare domain in the barriers section (and similarly for each major enabling factor, if possible). In the current format, the headings like “Primary healthcare:” or “Mental healthcare:” appear inline. Converting these to actual sub-headings (with numbering or at least bold lines) would make the document easier to navigate. This is a formatting refinement that the journal’s style might allow and would benefit readers, especially when quickly scanning for specific content (e.g., a reader interested mainly in mental health can find that section easily).

Response: Section subheadings have been demarcated and numbered.

 

1. Writing Style: Ensure consistency in tone. Most of the paper is written in an objective, academic tone, which is appropriate. Phrases like “This only deepens the barriers…” (line 109-111) might be better phrased more formally (“This further deepens the barriers…”). Also, avoid casual terms – for example, use “individuals” or “people” rather than “persons” for smoother reading (unless quoting an official title like “Human Rights Commission of Malaysia”). Overall, just minor polishing of language is needed; the tone is already scientific.

Response: The tone of the paper has been further polished by incorporating the given suggestions.

 

1. Length and Redundancy: The manuscript is somewhat lengthy, but given it’s a narrative review covering multiple facets, the length is acceptable. Just ensure every paragraph is necessary and adds value – there were a couple of instances that felt a bit repetitive. For example, the emphasis on UHC providing access but transgender needs not met is made in the Introduction and again later; make sure each mention adds new context. The conclusion could be more succinct – it currently restates many points. Try to focus the conclusion on the implications and next steps (e.g., the need for policy alignment and the importance of the findings for practitioners and researchers), rather than recapping all findings in detail.

Response: (Line 18-340). The conclusion has be modified and strengthened by replacing redundant information with constructive suggestions

 

1. Figures/Tables: Apart from Table 1, there are no figures. A suggestion (optional): a conceptual figure or model illustrating the intersection of barriers might be useful (for instance, a diagram showing individual, interpersonal, and structural level barriers and how they lead to outcomes). This is not strictly necessary, but in a journal on sexes, a figure highlighting the socio-ecological model of transgender health in Malaysia could be appealing. The authors might consider this if feasible, drawing on the content they already have.

Response: (Line 342) A figure highlighting the socio-ecological model of transgender health in Malaysia has been added.

Finally, the reflexivity and positionality statement is a noteworthy inclusion in terms of presentation and ethics. It is commendable that the authors identified their backgrounds and took steps to remain unbiased. Make sure this statement follows journal guidelines (its placement at the end before references is fine here). It adds transparency and is appropriate given the sensitive subject matter.

 Literature and References

The reference list is extensive and generally well-chosen, covering a mix of local studies, global research, and reports. Citations are up-to-date through 2025, which is excellent. There is a healthy number of Malaysian-specific sources (e.g., SUHAKAM 2019, local qualitative studies, national reports) alongside international literature. One concern is the reliance on self-citations: the authors cite several of their own works (Telang et al. 2025a; Telang et al. 2025b; Rashid et al. 2023; Rashid et al. 2021, etc.). While these are certainly relevant (and it’s natural to cite one’s related research), the authors should ensure they are not overweighting their interpretation based on their own findings.

In a review, it’s important to maintain a balanced perspective. I encourage adding additional independent references to complement the authors’ studies, especially if those external studies report similar findings – this will show that observations are not isolated to the authors’ work. I provide a list of suggested recent references below that could strengthen the manuscript. Each suggested work is from the last 5–10 years and relates to transgender healthcare access or outcomes. Integrating these will both update and broaden the review’s scholarly foundation.

Suggested Additional Literature for Inclusion:

The authors should consider citing and discussing the following peer-reviewed works to enhance the manuscript’s depth and currency:

1. Coleman, E. et al. (2022). “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” International Journal of Transgender Health 23(Suppl 1): S1-S259. – These recently updated international guidelines (WPATH SOC-8) outline best practices for gender-affirming care. While this is a very clinically oriented document, citing it could be useful when discussing the lack of gender-affirming services in Malaysia. It provides authoritative support for what components should ideally be available (e.g., hormone therapy, surgical aftercare, mental health support) and thus highlights the gap in the Malaysian healthcare system where such services are “absent from routine public healthcare,” as you note. Referring to SOC-8 could strengthen your call for integrating trans-specific health needs into national priorities and for healthcare policy reform.

Response: (Line 223-229) International guidelines recommend gender-affirming treatment, which includes hormone therapy, surgery, voice and communication therapy, and various aspects of primary and sexual healthcare for transgender women [54]. Following these guidelines, collaborations can be encouraged between healthcare professionals, policymakers, and community members who can advocate for affirming transgender healthcare. [54]. Flexible adoption of these guidelines will facilitate the integration of trans-specific health needs into national priorities.  

 

1. Ghosh, A. (2021). “The Politics of Alignment and the 'Quiet Transgender Revolution' in Fortune 500 Corporations.” Socio-Economic Review, 19(3), 1095–1125 – This study investigates how U.S. Fortune 500 companies adopted transgender-inclusive healthcare benefits by aligning LGBTQ advocacy with corporate values through non-confrontational strategies, particularly leveraging the Human Rights Campaign’s Corporate Equality Index. This “quiet revolution” succeeded not through protest, but via institutional alignment—demonstrating how transgender inclusion can advance within rigid systems when change appeals to organizational self-interest and legitimacy concerns. This insight has direct relevance to the Malaysian healthcare context addressed in the manuscript: it suggests that reforming public healthcare to support transgender women may depend on similar alignment between public health goals, institutional prestige, and sociocultural acceptability. Referencing this study would strengthen the manuscript’s arguments on overcoming structural inertia and developing enabling policies through strategic, context-aware engagement with institutions.

Response: (Line 295-2990 Building on insights from the ‘quite transgender revolution,’ transgender inclusion can advance within rigid systems when change aligns with organizational self-interest [72]. A relevant application to the Malaysian healthcare context involves overcoming structural inertia and developing supportive policies through strategic, context-aware engagement with institutions [72].

1. Ghosh, A. (2025). “Cultural Competence in Transgender Healthcare.” (Book chapter in Advancing Equity: Health, Rights, and Representation in LGBTQ+ Communities). – A very recent piece emphasizing the need for cultural competence among healthcare providers serving transgender patients. Including this reference would back up the manuscript’s section on “Inclusivity training for healthcare workers” as an enabling factor. It provides contemporary evidence and arguments that improving providers’ knowledge and attitudes (through education, policy reform, and community collaboration) can reduce systemic inequities – directly resonating with your recommendations for training and cultural safety.

Response: (Line 201-204) Education is a key pillar of cultural competence [51]. Improving healthcare providers' knowledge and attitudes, combined with policy reform and community collaboration, can help reduce systemic inequalities, paving the way for more personalized and respectful care [51].

 

1. Ghosh, A. (2020). “The Global LGBTQ Workplace Equality Movement.” In The Wiley Blackwell Companion to Sexuality Studies, pp. 445–463. – It explores how LGBTQ equality movements achieve progress differently across global contexts, emphasizing the need for localized strategies that reflect sociopolitical and religious conditions. In Malaysia, Ghosh notes that high structural stigma and religious condemnation force activists to prioritize instrumental goals like legal protections over expressive goals such as cultural acceptance. This distinction closely parallels the manuscript’s discussion on healthcare for transgender women, where institutional exclusion (e.g., lack of gender recognition, provider discrimination) impedes access. Citing this work would deepen the manuscript’s analytical grounding by framing Malaysia’s healthcare challenges within a broader global framework, reinforcing that targeted policy reform—tailored to local constraints—is essential for effective transgender inclusion in conservative societies.

Response: (Line 301-305) While framing Malaysia’s healthcare challenges within a broader global framework, it is noteworthy to reflect on the socio-political and religious conditions within the country [73].  Targeted policy reforms tailored to local constraints, focusing on institutional exclusion and provider discrimination, are essential for improving access to essential healthcare.

 

1. Hughto, J.M.W., Reisner, S.L., & Pachankis, J. (2015). “Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions,” Social Science & Medicine 147:222-231. – This review conceptualizes how multi-level stigma harms transgender health. Including it would provide a theoretical framework for several points in your manuscript – for example, linking interpersonal discrimination and structural stigma (laws, policies) to healthcare avoidance and mental health issues. It complements references like Poteat et al. 2013 that you cited, but is more recent and comprehensive in scope. It can strengthen the argument that stigma is a root cause of the healthcare access barriers noted in Malaysia, thereby justifying the need for interventions like provider training and policy reform.

 

Response: (Line 55-58) Transgender stigma persistently impacts the health and well-being of transgender individuals by functioning through a complex interplay between individual, community, and societal factors as described by the socio-ecological model [13].

 

1. Maoto, M. & Davis, B. (2024). “Breaking barriers: How transwomen meet their healthcare needs,” African Journal of Primary Health Care & Family Medicine 16(1):4598. – A recent qualitative study from South Africa (another context of the Global South) which explored transgender women’s experiences with mainstream healthcare and their alternative strategies to obtain care. The findings mirror many issues raised in your review: widespread discrimination in health facilities, resorting to self-medication or community networks, etc. Citing this study would provide a comparative perspective, showing that many barriers faced by Malaysian trans women (stigma, lack of access to hormones, etc.) are also documented in other regions. This can underscore the significance of your recommendations — for instance, the need for inclusive health management is echoed by Maoto & Davis’s conclusion that equitable and inclusive healthcare is urgently needed for transwomen. Including it also broadens the manuscript’s appeal to an international readership by connecting local findings to global patterns in transgender healthcare.

Response: (Line 248-250) Drawing from similar contexts involving transgender women in a South African study, equitable and inclusive health management can be achieved through novel strategies such as collaborating with traditional healers to enhance access to healthcare [57].

 

1. Winter, S. et al. (2016). “Transgender people: health at the margins of society,” The Lancet 388(10042):390-400. – Part of The Lancet’s series on transgender health, this article examines global health disparities faced by transgender people, especially in Asia-Pacific. Citing Winter et al. would situate the Malaysian findings in a global context – for instance, reinforcing how stigma and exclusion lead to poor health outcomes worldwide. It can bolster your introduction or conclusion when arguing that the issues in Malaysia reflect broader patterns that require rights-based approaches (the Lancet piece strongly advocates that transgender rights are critical for health).

 

Response: (Line 285-286) Stigma and exclusion faced by transgender women are linked to poor health outcomes worldwide, highlighting the importance of transgender rights for health [66].

The above references are suggestions to improve the manuscript’s scholarly grounding. Including them will demonstrate engagement with up-to-date literature and situate the Malaysian context within the broader field of transgender health and sexuality studies.

 

To conclude. let me first acknowledge that this review addresses a vital topic. The manuscript is well-intentioned and contains valuable information for both healthcare providers and researchers. The multidisciplinary consideration – covering primary care, sexual health (HIV/STI), oral health, and mental health – is a strong point; it recognizes that transgender women’s healthcare needs are holistic. The inclusion of Malaysian data and reports (e.g. SUHAKAM, Ministry of Health reports, local studies) gives the review local relevance and practical significance. The discussion of enabling factors is forward-looking and offers constructive ideas that policymakers and community organizations could act upon. The reflexivity statement demonstrates ethical care. These strengths mean that, after revision, the paper could make a meaningful contribution.

However, to reach that point, the manuscript needs major revisions in the areas noted above. I summarize the most critically needed changes here:

1. Improve methodological transparency. Clearly describe how the literature was gathered. Even if it is not a systematic review, provide enough detail so readers trust that this narrative review is comprehensive and not biased. Outline the scope (years considered, types of sources, any focus on certain study designs or populations). This will significantly boost the paper’s credibility.
2. Enhance clarity and organization. Rework the structure to ensure sub-sections are well delineated. Edit language for conciseness and fix any grammatical errors. These changes will make the manuscript more reader-friendly. A well-structured paper is particularly important for an interdisciplinary audience (some readers from social sciences, some from health sciences), so clarity is key.
3. Deepen the analysis. Go beyond summarizing facts by adding interpretive commentary. For example, after listing various barriers, synthesize them: “Taken together, these studies suggest that beyond individual bias, institutional policies (like gendered wards and legal ID) systematically marginalize transgender women, aligning with the concept of structural stigma.” Similarly, in the enablers section, acknowledge feasibility or evidence level: “While initiatives like STI-friendly clinics show promise, their long-term efficacy remains to be evaluated, indicating a need for implementation research.” Adding such analysis will show the authors’ critical engagement with the material, not just a descriptive account.
4. Incorporate additional pertinent literature. As detailed in the list above, there are several recent works that would strengthen your arguments. Works on cultural competence in transgender healthcare, adoption of transition-related health benefits, and global inclusion of transgender persons can provide sociological depth on transgender issues in contexts like Malaysia. The global health studies (Winter et al., Poteat et al., etc.) can reinforce the significance of your observations. These will guard against the appearance of any gaps in knowledge. It will also ensure the manuscript resonates with the sex and sexualities studies field by connecting to broader scholarly conversations.
5. Address ethical considerations. Although this is a review, you have handled ethical aspects well by disclosing authors’ positionality and stating lack of conflicts. One additional point: be mindful of any potential self-plagiarism. If text from your own prior publications (such as the 2025 studies you cite) was reused, it must be rephrased or quoted. From my reading, the text seems original (I did not detect obvious overlap with other texts), but it’s worth double-checking to avoid any inadvertent text duplication. Since you cite your previous studies, you likely have paraphrased appropriately; just ensure no lengthy passages are copied verbatim. The journal may run a plagiarism check, so it’s best if you preemptively ensure originality of phrasing.

Given these required revisions, I recommend “Reconsider after Major Revision.” The paper has potential and is on a worthwhile topic, but it is not yet ready for publication in its current form. I encourage the authors to revise thoroughly, as I believe the manuscript could be much improved with the above changes. The additional context and clarity will make it a more impactful resource on transgender healthcare in Malaysia, bridging public health and sexualities research in a meaningful way.

 

Comments on the Quality of English Language

The manuscript is generally well-written, with a clear academic tone and appropriate terminology. However, several sections would benefit from careful proofreading to improve sentence clarity, grammar, and conciseness. In some instances, the narrative becomes wordy or vague due to abstract phrasing and passive constructions (e.g., “creating an entry point,” “only a few methods have been put in place”). Paragraphs can also be dense, with long sentences that hinder readability. Attention to parallel structure, active voice, and consistency in terminology (e.g., “transgender women” vs. shorthand terms) would enhance the overall fluency and precision of the text. While the English is intelligible throughout, a thorough copy-edit is recommended to bring the language up to the standards of a high-impact academic journal.

Response: Every effort has been made to improve the quality of the English language with the help of editing where necessary.

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Overall my comments have been sufficiently addressed.

Major Comments: My first comment has been thoroughly addressed.

My second comment has been addressed.

Minor Comments: Citation formatting is much better, but there are still errors.  Just in the introduction, some citation numbers are after the punctuation, and some citations in lists are still in individual square brackets.

All abbreviations appear to be defined at first use.

The sentence is clearer but you have not elaborated on the ways in which religious beliefs affect access to mental health and access to mental healthcare.

Author Response

Author's response:

Thank you very much for taking the time to review the edited version of the manuscript. We have made our best effort to implement the suggested changes.

Reviewer 1 comments:

Overall my comments have been sufficiently addressed.

Major Comments: My first comment has been thoroughly addressed.

My second comment has been addressed.

Minor Comments: Citation formatting is much better, but there are still errors.  Just in the introduction, some citation numbers are after the punctuation, and some citations in lists are still in individual square brackets.

Response: All references have been reviewed again and revised to maintain uniform referencing style as outlined by the journal. 

All abbreviations appear to be defined at first use.

The sentence is clearer but you have not elaborated on the ways in which religious beliefs affect access to mental health and access to mental healthcare.

Response: To bring in more clarity, information has been added. “In Malaysia, where religion plays a central role in shaping social norms, transgender women often face stigma due to interpretations of religious teachings that reject gender diversity [10]. This not only impacts their mental well-being by fostering internalized shame and social exclusion [19], but also creates barriers to accessing mental healthcare, as some providers may allow religious beliefs to influence their attitudes and treatment practices [22,48].”