Reviewer’s report
Title: Association between type 1 diabetes and female sexual dysfunction
Version: 1 Date: 02 Jan 2020
Reviewer: Linda Vignozzi
Reviewer's report:
The aim of this study was to investigate the prevalence of female sexual dysfunction (FSD) in a
population of women affected by type 1 Diabetes Mellitus (DM1) and the association between sexual
dysfunction and different characteristics of this chronic disease, such as its duration, HbA1c levels,
BMI, methods of insulin administration and diabetes complications. The topic of the paper is certainly
interesting, since DM1 affects a large population of women in their fertile age who are sexually active.
Moreover, this study can contribute to fulfilling the gender gap in sexual medicine regarding the
association  between  sexual  dysfunction  and  dysmetabolic  conditions,  which  has  been  certainly
investigated more widely in the male population so far. However, there are some concerns to address,
particularly for what regards:
-Background: you should enrich this section taking into account this paper by Maseroli et al.:
"Cardiometabolic Risk and Female Sexuality: Focus on Clitoral Vascular Resistance." (Maseroli E et
al., J Sex Med. 2016 Nov;13(11):1651-1661. doi: 10.1016/j.jsxm.2016.09.009. Epub 2016 Sep 28.
PMID:  27692844),  which  reports  a  positive  association  between  clitoral  vascular  resistance  (as
assessed  by  clitoral  ecocolorDoppler  ultrasound)  and  metabolic  syndrome  (in  particular  insulin
resistance),  decreased  sexual  arousal,  body  image  concerns,  and  increased  somatized  anxiety
symptoms;
-Background (Page 3, lines 20-23): the sentence "In the literature…[…]…and classification of
severity" should be corrected, since it contains some typing and grammatical errors;
-Background: you should provide the prevalence of DM1 in the Italian fertile female population;
-Material and Methods: inclusion criteria should be better specified - i.e. were the diabetic
women of the sample consulting the Endocrinology and Diabetology Unit only for diabetes or for
female sexual dysfunction, as well? Moreover, it is not clear how and from which population the
women of the control group were recruited; 
-Material and Methods: the association between sexual dysfunction and metabolic risk factors in
women is still strongly debated in literature, mainly because this relationship has been primarily
investigated by using low-quality outcome measures such as sexual satisfaction questionnaires. This is
a fundamental limitation of the study. Please explain why you did not use the extended version of the
FSFI (made up of 19 items), which would provide more details about female sexual function;
-Results: the comparisons regarding the number of previous pregnancies should be summarized
in a table, since the heterogeneity in the reproductive state of the patients could represent a limitation of
the study;
-Discussion: you should enrich this section taking into account a recent review focusing on the
association between  cardiometabolic risk factors  and female sexuality,  which  provides  interesting
insights about the mechanisms of peripheral arousal response in women and evidence from clinical
studies about the increased risk for FSD due to cardiometabolic alterations ("Cardiometabolic Risk and
Female Sexuality-Part I. Risk Factors and Potential Pathophysiological Underpinnings for Female
Vasculogenic Sexual Dysfunction Syndromes." Maseroli E et al., Sex Med Rev. 2018 Oct;6(4):508-
524. doi: 10.1016/j.sxmr.2018.02.009. Epub 2018 May 2. Review.PMID: 29730315; "Cardiometabolic
Risk and Female Sexuality-Part II. Understanding (and Overcoming) Gender Differences: The Key
Role of an Adequate Methodological Approach." Maseroli E. et al., Sex Med Rev. 2018 Oct;6(4):525-
534. doi: 10.1016/j.sxmr.2018.03.004. Epub 2018 Apr 13. Review. PMID: 29661689);
-Tables 1, 2, 4: could you please provide the p values instead of "NS"?
-In the text there are some grammatical errors for which a linguistic revision is recommended.
-The prospective design of the study, the significant heterogeneity in the reproductive state of the
patients of the two groups (diabetic women and control group), the assessment of female sexual
function only by using a questionnaire (i.e. data regarding BMI could be enriched by the use of a
questionnaire which explores body uneasiness and dissatisfaction, such as the BUT, Body Uneasiness
Test;  patients  could  undergo  a  clitoral  ecolorDoppler  ultrasound,  in  order  to  obtain  an  objective
measurement of genital vascularization), and the lack of hormonal parameters of the study population
(i.e. did the two groups differ for testosterone levels?) represent major limitations of the paper. If these
are not improvable, you should at least mention them in the Conclusions.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Unable to assess
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
Are you able to assess any statistics in the manuscript or would you recommend an additional
statistical review?
If  an  additional  statistical  review  is  recommended,  please  specify  what  aspects  require  further
assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Needs some language corrections before being published
Declaration of competing interests
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4. Have you received reimbursements, fees, funding, or salary from an organization that holds
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