Review 1: "Gender-affirming Care, Mental Health, and Economic Stability in the Time of COVID-19: A Global Cross-sectional Study of Transgender and Non-binary People"

RR:C19 Evidence Scale rating by reviewer:

• Reliable. The main study claims are generally justified by its methods and data. The results and conclusions are likely to be similar to the hypothetical ideal study. There are some minor caveats or limitations, but they would/do not change the major claims of the study. The study provides sufficient strength of evidence on its own that its main claims should be considered actionable, with some room for future revision.

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Review:

The preprint of “Gender-affirming care, mental health, and economic stability in the time of COVID-19: a global cross-sectional study of transgender and non-binary people” represents a study with a Reliable strength of evidence. This manuscript covers a relatively understudied area of scholarship during the COVID-19 pandemic – the impact on transgender and non-binary populations. Although the preprint does a good job of situating the importance of the research, it remains unclear why there is a need to expand beyond the US to understand the impact of the pandemic, since the impact in the US has also been relatively unstudied. This is not to say that a global perspective is not important, but the different circumstances (legal protections for transgender and non-binary individuals, national responses to the pandemic, etc.) necessitate a deeper exploration of the global contexts in which participants live. As a result, not including WHO region as a covariate in models is a significant limitation to interpretation. Further, although change in living situation was posited as an important factor in mental health in the Introduction, this variable seems not to have been included in the analyses. A more minor concern is the incorrect interpretation of PrRs – a PrR of 1.63 indicates something is 1.63 times as likely, not 1.63 times more likely. Several data limitations were not highlighted, which is problematic for understanding the results. All study participants were recruited from social networking apps for sexual minorities – therefore, the sample is likely comprised of predominantly sexual minority individuals. Individuals with multiple minoritized identities (in this case, sexual orientation and gender identity) are likely to be more greatly impacted by negative health conditions. Although participant sexual orientation isn’t necessarily germane to the aims of this study, the sampling method indicates that this should at least be included in the demographics table. More information is also needed about the limited sample of transmasculine, since that makes any inference about differences difficult. Further, it seems there were no questions specific to COVID-19 – how many participants had tested, had symptoms, or were diagnosed with COVID-19? Overall, this is a well-written paper with several areas in need of additional attention. My recommendation is that this preprint undergoes a major revision.