Title: Sexual behaviors and vulnerability to sexually transmitted infections among transgender
women in Iran
Version: 1 Date: 13 Jul 2021
Reviewer's report:
Thank you for the opportunity to review this manuscript. It focuses on the sexual behaviors of
Iranian transgender women. While these are fantastic data and definitely worthy of publication,
there are several issues in the manuscript that first need to be addressed. One is the conflation
of AIDS and HIV infection. There are also several areas where more supportive language be
used. I would also recommend to the authors that they do a more detailed analysis of the effects
of vaginoplasty on sexual behavior as this seems like a missed opportunity with this data set as
some data have shown a protective effect of gender affirming surgery. In general, there is an
opportunity to discuss predictors of condomless sex that is missed. There is also an assumption
that employment status is a predictor of sexual risk, and this is not explored, but seems to
permeate the manuscript throughout.
As a whole, the article suffers from underdeveloped data analysis. I would encourage the authors
to do more involved data analysis including regressions and factors that affect different variables
like bodily satisfaction and sexual satisfaction. A report of descriptive findings from the study
is interesting, but more detailed analysis would vastly improve the article.
Background – why is it essential to pay special attention to the sexual health of transgender
women? Please support this statement or include more detailed, but brief, background. For
example, discuss HIV prevalence from global or other countries’ studies, data from Brazil on
STI rates
Methods – where was the study done? What was the context for care? This is the abstract, but
it is still important to include details
Background – please avoid stigmatizing language like “infected.”
Page 3 line 45-46 – please define transgender women as “those who have a male sex assigned
at birth who are living in a female gender identity” or similar. It is more than “uncomfortable.”
Page 3 line 57 – please omit “prostitution” as this has pejorative connotations. Please say instead
“trade sex for x,y,z” based on the citations you are using.
Line 55 – talk about specifics of employment discrimination; there is a lot of discrimination that
trans people face, but this is specific to employment which functions in a specific way.
Page 3 line 58 – sexual health problems? General health problems? Citation supports discussion
of multiple health problems, not all of which are related to sexual health, so this does not flow
or follow particularly well
Page 3 line 59 – do you mean AIDS or HIV infection? Citation supports HIV infection, but not
AIDS diagnosis.
Page 3 line 61 – sex adaptation should be changed to gender affirmation. Please distinguish
silicone use, IVDU, hormone injection
Page 4 line 63 – there is an update to the NCTE survey published in 2016 – the US Trans Survey.
Please update number to more recent data.
Line 67 – “official statistics” - please elaborate source. Governmental report? How were data
collected? Please compare rates of sex outside of marriage with cisgender population for context.
Lines 70-73 – this is redundant. Also, please be specific to Iran in this paragraph and move other
citations to earlier paragraph talking about risk.
Methods – how was sample recruited? Was it online? In person? Interviews? Surveys? You may
have published details on this study in other articles, but please reiterate here. Was there any
community participation or oversight of this work? Please elaborate on community involvement
and state if there was no community involvement.
Participants – fold this in with methods, and again, elaborate on who the people were who ere
selected. It sounds like they were sent surveys? Change “start treatment” to “engage in gender
affirming medical and surgical care.” Methods in general are too vague. Were trans people who
did not “start treatment” available at the center? Why were they not included?
Research tools – again, this should be in a larger general methods section and moved up.
Line 134 – define “sex experience.” Is this any sexual contact? Receptive penetrative sex? Also,
this entire section would benefit by splitting analysis between those who did and did not have
vaginoplasty. There is an interesting sub-question here about the ways surgery can affect sexual
satisfaction that is largely missed.
Line 135 – please differentiate between anal and vaginal dyspareunia
Line 141-144 – this was addressed in methods. This paragraph can be removed.
Line 153-157 – please address frequency of bacterial STIs, HSV, HPV among those who had
a history of STI infection. Additionally, how much of the sample had been tested for STIs? It
seems like there was no validation with current testing at the time of admission of the ?survey?
so please make this more clear.
Line 158-163 – AHA! Please move this paragraph to before frequency of STIs as it is important
for interpreting those data.
190-191 – please avoid value judgements like “unpleasantness” and more specifically discuss
the findings in cisgender women and how they are echoed in transgender women.
Line 200 – please elaborate on sexual function and how this compares to other orgasmic
disorders. This seems vague and should be better explained.
Line 201 to 202 – please remove the section about having a penis. This seems like pure conjecture
and does not add anything to the article. A larger discussion of sexual pleasure and anorgasmia
is warranted. Again, this section would benefit from discussion of those who have and have not
had vaginoplasty.
Line 205 – what is a “proper orgasm?”
Line 210 – husband or sexual partners? It seems awkward to use the word husband here when
so few participants were married, and there is no comparison between married and single
participants
Line 211-213 – do you have data on what interventions people have had and how this affects
satisfaction? Perhaps duration on time of hormones, gender affirming surgeries including but
not limited to vaginoplasty
217 – presumably the comparison is with cisgender women, or were transgender women
included in the comparison data? Please specify.
Line 218 – again, further analysis into factors correlating with painful sex would be helpful. Is
number of partners a factor? Surgical status? Etc.
Line 233 – this is a key finding. Please add to results section.
Lines 261 – 263 – you haven’t really determined that this is due to having a penis; sexual
practices seem different enough from cisgender women that this may not be relevant. It
also seems unclear whether or not participants were asked if they use their penis for sexual
gratification, which would be a key indicator to back up this assertion.
Lines 266-268 – lack of stratification based on genital status makes it difficult to comment on
efficacy of surgeries as much of the dyspareunia reported is in anal receptive sex. This assertion
would be better supported with more thorough data analysis.
Lines 269-271 – the assertion about employment being a factor is not addressed in the data.
More directly tackling this question in the data would help elucidate the causes and potential
solutions to increased risk.