Title: Sexual behaviors and vulnerability to sexually transmitted infections among transgender
women in Iran
Version: 2 Date: 10 Oct 2021
Reviewer's report:
Summary:
This manuscript assesses sexual behaviors, risk for STIs, some aspects of sexual function, sexual
satisfaction, body satisfaction, and gender affirming procedures among transgender women
in Iran. The authors should be commended for addressing a relatively understudied topic,
particularly for the region. However, I have some concerns about the framing of the manuscript,
the reporting of the results, and overinterpretations of the findings.
Title:
- I think it’s important to situate these findings to context – I would change the title to “Sexual
behaviors and vulnerability to sexually transmitted infections among transgender women in
Iran”
Abstract:
- Given the significant association between vaginoplasty and sexual satisfaction, please specify
the number of women in the sample who had a history of gender-affirming surgical procedures.
- In the conclusion, the authors state that the “sexual interests of Iranian transgender women were
aligned with those of cisgender women”. This is not a conclusion that are based on these data,
as cisgender women were not included in the analyses. Please clarify which group of women
are being referenced or remove.
- In the conclusion, the authors speculate that body satisfaction and lack of vaginoplasty are
driving sexual satisfaction among transgender women. It’s unclear if this speculation is data
driven – are these data included in the analyses? Does other research on this population speak
to these results? Relatedly, they also conclude that there is a need for “more effective surgeries”
when, in the prior sentence, they state that the problem may be the lack of available surgeries.
Is the issue that surgeries aren’t widely available to those who need them, or that the surgeries
are not effective?
Introduction:
- Pg. 3, lines 51-53: I would be very careful with the wording of this definition. The reference
here isn’t appropriate. See APA glossary (https://www.apa.org/monitor/2018/09/ce-corner-
glossary) or similar resource from a local Iranian organization.
- Pg. 3, lines 52-53: The authors state that “few studies have been conducted on sexual behaviors
and preferences of transgender people”. At this point, this statement is no longer true globally
– however, this may very well be the case in Iran. Please clarify.
- Pg. 3, lines 56-60: Are there any more recent data than the European studies conducted in
2013-14? And are there any data on sexual activity and condom use that are specific to Iran or to
other countries in the region? And is the preference for anal sex specific to transgender women
rather than transgender people? Seems to be an overgeneralization, but if the data overwhelming
suggest that is true, then I may very well be wrong.
- Pg. 3, lines 61-63: Again, is this information specific to Iran? It would be best to situate the
paper in the country or region in which the data were collected. It is true that transgender people
face widespread discrimination, but what does that discrimination look like in Iran?
- Pg. 4, lines 65-72: Though I appreciate the inclusion of CDC data and the findings of the
National Center for Transgender Equality, these data are based in the US and may not be
appropriate for the Iranian context. If at all possible, please include Iranian or regional data (as
was included in lines 73-80 on this same page).
- Pg. 4, line 74: In the US, we now refer to these procedures as “gender-affirming surgeries”.
Is that the case in Iran?
- Pg. 5, lines 85-86: It seems that relationships with gender affirming procedures were also
explored. These analyses appear to be central to the manuscript and should be included here.
Methods:
- Pg. 5, lines 94-95: Please clarify the inclusion and exclusion criteria here.
- Pg. 5, lines 98-99: What is meant by “no community participation”? Based on earlier
descriptions, it seemed like women were recruited from community health centers via
convenience sampling?
- Pg. 5, lines 102-103: Can you clarify what types of gender affirming care were provided
by these clinics (e.g., which surgeries [facial feminization, vaginoplasty, facial vocalization],
hormones, counseling).
- Pg. 5, lines 104-105: Were any validated sexual behavior questionnaires available in the local
language? If not, this needs to be cited as a limitation.
- Pg. 6, lines 107-108: Assessing whether sex partners have had sex with other people is
challenging – were any steps taken to increase the accuracy of these data?
Results:
- Pg. 8, lines 159-161: It is unclear how oral and anal sex “were inevitably the third frequent
sexual behavior due to the lack of vaginoplasty in the majority of transgender women”.
- Pg. 8, line 165: The authors note that the majority of participants didn’t know any of the
symptoms or complications of STIs, but the percentages that they provide for these results do
not reflect the majority (33.9% and 44.1%, respectively).
- Pg. 8, lines 171: Please clarify which disease 82.6% of participants had been treated for.
Discussion:
- Pg. 9, lines 186-187: Please clarify the specific pathways through which legal restrictions on
sexual activity outside of marriage lead to high-risk behaviors.
- Pg. 9, line 187: Please replace “AIDS” with “HIV”.
- Pg. 10, lines 201-202: I would rephrase the following: “In this study, 70% of participants had
sex for money and therefore, they were willing to perform any type of sex even against their
will”. I don’t think this conclusion is generally true for people who engage in sex work.
- Pg. 10, lines 209-212: Please be careful to avoid over interpreting the results. The authors
conclude that “the results of this study showed that vaginoplasty had no effect on achieving
orgasm in transgender women”. However, the actual results reported are purely descriptive –
no correlations were run, and no models assessed the relationship between vaginoplasty and
orgasm.
- Pg. 11, lines 213-214: The authors state that, “despite reaching orgasm, transgender women did
not report high sexual satisfaction and 41.6% of them reported low and very low satisfaction…”
Though orgasm and sexual satisfaction may be correlated, they are distinct constructs – the
sexual experience is multifaceted, as are the factors that predict sexual satisfaction. The way that
this section is written oversimplifies these relationships.
- Pg. 11, lines 218-219: The authors state that “vaginoplasty showed a significant association
with sexual satisfaction”. This is not true – analyses that would indicate an association were
not conducted (or the results of such analyses are not described in the results section of the
manuscript). Please address and clarify.
- Pg. 11, lines 221-223. Please include appropriate references to back up this point.
- Pg. 11, lines 223-224: It is a strong overgeneralization to state that “hormone therapy reduces
body dissatisfaction”.
- Pg. 12, lines 241-242: Is this statement specific to Iran? Please clarify and cite.
- Pg. 13, lines 271-272: Rather than starting the conclusion with a very general statement that
is not really specific to the findings of this study, please summarize key results and frame
the interpretation within the Iranian context. Once the authors have done so, more general
conclusions can be made.
- Pgs. 13-14, lines 275-279: Many comparisons with cisgender women are being made here –
please clarify that the cisgender findings are from other studies (as cisgender women were not
included in this sample) and cite those studies.
- Pg. 14, line 279: Again, it is unclear how these data suggest that “more effective surgeries”
may be needed.
- Pg. 14, lines 282-284: This conclusion about jobs and finances seems out of place at this point
in the manuscript.