{'fraction_non_alphanumeric': 0.03029686864579097, 'fraction_numerical': 0.013555645926528399, 'mean_word_length': 5.022448979591837, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 1, 'lorem ipsum': 0, 'www.': 1, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Risk of poor mental health and experience of violence among a young adult population with same-sex sexuality: a cross-sectional study in southern Sweden

Objectives To assess prevalence and correlates of same-sex sexuality and its relationship to poor mental health and experiences of violence among youth and young adults in Sweden. A secondary aim was to estimate the same-sex sexuality attributable fractions. Design A population-based cross-sectional survey. Setting Southern Sweden. Participants 2968 respondents out of 7000 youth and young adults between 18 and 29 years old, resident in southern Sweden, selected randomly by the Swedish Central Population Registry (final sample=2931 respondents, 318 with same-sex sexuality and 2613 without). Outcome measures The outcome measures were self-reported poor mental health (depression and anxiety) and experience of violence (physical violence, sexual violence and sexual coercion). Results Increased odd of high scores of depression (adjusted OR 1.8, 95% CI 1.39 to 2.26) and anxiety (adjusted OR 1.6, 95% CI 1.28 to 2.07) were observed among youth and young adults with same-sex sexuality. Similarly, increased odds of experience of physical violence (OR 1.8, 95% CI 1.23 to 2.51), sexual violence (OR 2.8, 95% CI 1.96 to 3.89) and sexual coercion (OR 2.5, 95% CI 1.95 to 3.30) were observed with same-sex sexuality. Within the entire young population, same-sex sexuality accounted for 4.7% and 4.1% of the self-reported experience of depression and anxiety, respectively. The estimated same-sex sexuality attributable fractions of violence within the entire population of young people were 4.5% for physical violence, 7.3% for sexual violence and 6.4% for sexual coercion. Conclusions This study findings suggest that same-sex sexuality is associated with poor self-rated mental health and experience of violence among youth and young adults in Sweden. Some differences were observed between males and females, indicating that the vulnerabilities and experiences vary between young males and females. Further research is needed in order to gain a deeper knowledge of the factors underlying these associations and the gender differences observed.

-In the introduction section, the authors correctly recognize that sexuality can be measured across multiple domains. With that said, I am curious to know why the authors elected to use measures of sexual behavior and orientation in their study, but not sexual attraction, which has been found to be more stable (less fluid) in sexual minority youths.
-What is the reference for defining "youth" as ages 18-24 and "young adult" as 25-30? -The decision to dichotomize the mental health scores using a median split is questionable. What is the clinical significance of the median value? Why not use a clinically supported categorization instead? The high/low split is much more difficult to meaningfully interpret than cutoffs representing levels of symptom severity.
-Is the only rationale for assessing physical and sexual violence within the past 12 months (versus lifetime) to minimize recall bias? If so, a reference supporting this approach would be valuable. -As limitations, the authors should comment on the generalizability of the study's results beyond Sweden and response bias (as respondents appeared to have a female predominance).
I look forward to reviewing a revised version of the manuscript.

GENERAL COMMENTS
I would like to congratulate the authors for a well written article! 1. The population attributable fraction (PAF) is widely used to assess the public health impact of exposures in populations, which the authors clearly indicated in this study. However, it would be interesting to add preventive strategies or policies that benefit general population in mitigating the risks of poor mental health and violence. If such polices are inaccessible for the group studied, what would the authors recommendation to help policymakers in planning public health interventions targeting poor mental health and violence among youth and young population with same-sex sexuality? This might be mentioned briefly in the discussion part of the article. 2. On page 19: Your findings suggests that "4.2-7.3% of risk reduction associated with poor mental health violence among youth and young population in Sweden". Firstly your data is based residents in Skåne comprised of 318 respondents who reported same-sex sexuality. Given the size of the study population and geographical limitation how was the issue of generalizability inferring to youth and young population in Sweden?

VERSION 1 -AUTHOR RESPONSE
Reviewer #1: This manuscript examines links between same-sex sexuality, mental health outcomes, and experiences of violence among youth and young adults in Sweden. Strengths of the study include a relatively high response rate (45%) for a population-based survey and the use of multiple measures of sexuality (sexual behavior, orientation).
1. In the introduction section, the authors correctly recognize that sexuality can be measured across multiple domains. With that said, I am curious to know why the authors elected to use measures of sexual behavior and orientation in their study, but not sexual attraction, which has been found to be more stable (less fluid) in sexual minority youths.
Response: Thank you for this comment. The questionnaire did not include a specific question regarding sexual attraction since the overall purpose of the survey was to map young people's lifestyles and behaviors. Moreover, we regard the two measures, i.e. sexual orientation and sexual relationships, as providing adequate and robust indicators of same-sex sexuality, as sexual attraction in itself need not entail activities or behavioral aspects.
We have added the following text to the discussion: "A possible limitation is that the survey instrument did not include a specific question regarding samesex sexual attraction. However, we regard the two measures, i.e. same-sex sexual orientation and sexual relationships, as providing adequate indicators of same-sex sexuality, as sexual attraction in itself need not entail activities or behavioural aspects." (Page 25).
Response: Thank you for this comment, we have added a reference regarding our dichotomization of the age groups and added a text on our use of the terms. We follow the UN definition of youth, which defines youth as those between the ages 15 and 24 years. This definition guided the dichotomization and labels of the two groups. Our sample ranged from 18 to 30 years, meaning that youth aged below 18 were not included in the study. The terms "young adult and young adulthood" have been used to describe a number of different age groups, sometimes exceeding the 30s. As this term is not strictly defined, for example in the UN system, our use of the term should be understood as a classification of the participants who are no longer youth, and we found young adults as a useful term describing these participants. In this study we use the term "youth" to describe those participants who are 24 years or below, in accordance with the UN definition of youth (ref). We use the term "young adults" to describe the participants who are older, i.e. 25 years or above.
The classification of age group in the study has been revised for clarity as follows: "According to the UN definition of youth ( 3. The decision to dichotomize the mental health scores using a median split is questionable. What is the clinical significance of the median value? Why not use a clinically supported categorization instead? The high/low split is much more difficult to meaningfully interpret than cutoffs representing levels of symptom severity.

Response:
We agree that the median value does not have a clinical significance as such, in that it does not correspond to any clinical diagnostic category. However, it is important to note that although widely used as a research tool, the HSCL cannot be used as a diagnostic instrument as such, because there is no established severity level or cut-off point that corresponds to any particular diagnosis. Thus, it is not possible to perform any clinically "supported" categorization. Lacking such categorization, we used the sample median to differentiate between persons having "high" and "low" symptom levels, without attempting to interpret these levels further. Any such attempt would have been arbitrary, without access also to a clinical interview.
We have added the following text to the discussion: "A limitation of the HSCL is that it does not provide the basis for establishing clinical "caseness" as such, as it is not a diagnostic instrument." (Page 25) 4. Is the only rationale for assessing physical and sexual violence within the past 12 months (versus lifetime) to minimize recall bias? If so, a reference supporting this approach would be valuable.

Response:
Thanks for the comment. The 12 months cut-off, although arbitrary, is a standard cut-off widely used globally in research on physical and sexual violence. Surveys of physical and sexual violence generally ask about respondents' exposure within their lifetime and in the past year, with few studies enquiring about the experiences within a shorter period of time such as in the last month. The WHO defines current prevalence among women as reporting that at least one act of physical or sexual violence, or both, took place during the 12 months prior to the interview Thus, in this study, the experiences of physical and sexual violence measured was present/current experience, which followed the WHO definition as indicated above and was thus limited to the experience in the last 12months.
As we indicate in the methodological considerations, the shorter period used (last 12 months compared to lifetime experience could reduce recall bias due to the shorter exposure period. We have revised the following statement and included a reference: "This was a cross-sectional study based on self-reported, retrospective information. As such, this creates a potential risk for recall bias, which could result in error due to misclassification of measured variables. Some items in the questionnaire referred to present experiences or recent exposure, for example, by specifying "during the last 12 months", which could minimize the risk of recall error due to the shorter exposure period ( As limitations, the authors should comment on the generalizability of the study's results beyond Sweden and response bias (as respondents appeared to have a female predominance).

Response:
Thanks for this comment. Generally, the population in Sweden (including Southern Sweden) has had a higher female to male ratio until 2015 (https://www.statista.com/statistics/521540/swedenpopulation-by-gender/). However, we agree that the greater proportion of female respondents in this study could potentially affect the broader generalizability of this study, albeit not to any appreciable extent.
We have included the following statement in the discussion of methodological consideration: "The proportion of female respondents in this study was slightly higher than male respondents, which could potentially affect the generalizability of the finding, albeit not to any appreciable extent." (page 26) "Although the findings of this study may be generalizable to similar populations nationally in Sweden and beyond, caution may be warranted to ensure that those populations have comparable context and demographic characteristics." (page 26) Reviewer #2 I would like to congratulate the authors for a well written article! 1. The population attributable fraction (PAF) is widely used to assess the public health impact of exposures in populations, which the authors clearly indicated in this study. However, it would be interesting to add preventive strategies or policies that benefit general population in mitigating the risks of poor mental health and violence. If such polices are inaccessible for the group studied, what would the authors recommendation to help policymakers in planning public health interventions targeting poor mental health and violence among youth and young population with same-sex sexuality? This might be mentioned briefly in the discussion part of the article.
Response: Thank you for the comment. We have added the following text in the discussion section: "It could be potentially beneficial to improve available sexual violence and poor mental health detection tools in public institutions within and outside of the health care system so as to ensure early detection of 'early warning signs of exposure to violence and poor mental health' among young people, with particular emphasis on same-sex sexuality youth. This could offer opportunities for targeted preventive interventions." (page 24) 2. On page 19: Your findings suggests that "4.2-7.3% of risk reduction associated with poor mental health violence among youth and young population in Sweden". Firstly, your data is based residents in Skåne comprised of 318 respondents who reported same-sex sexuality. Given the size of the study population and geographical limitation how was the issue of generalizability inferring to youth and young population in Sweden?
Response: Thanks for your comment. As noted in the introduction "Population-based studies in Sweden have shown that 0.7 -0.8% of adult respondents self-identified as lesbian/gay and 1.2 -1.8% as bisexual 1. However, studies among youth in Sweden have yielded higher proportions of lesbian, gay or bisexual (LGB) identities 2-5 and the figure regarding same-sex sexual behavior might be even higher." The 318 respondents who reported same-sex sexuality represents 10.8% of the total respondents (total sample, 2931). Thus, this is a fairly high proportion given the statitstics indicated above. We have revised the text in the Discussion as follows: "The same-sex sexuality attributable fractions for both poor self-reported mental health and experience of violence in this study give a clear indication of appreciable public health benefits (4.1 -7.3% population risk reduction) of interventions targeted towards reducing the excess burden of poor mental health and violence among youth and young people with same-sex sexuality in Southern Sweden." (page 24) We have also included the following statement on generalizability: "Although the findings of this study may be generalizable to similar populations nationally in Sweden and beyond, caution may be warranted to ensure that those populations have comparable context and demographic characteristics." (page 26) We thank you for the helpful comments and have taken due consideration to the points raised in the revised version of the manuscript. Please see the specific responses below.