Reviewer’s report
Title: 
Middle-aged Lebanese women interpretation of sexual difficulties: A
qualitative inquiry
Version: 
0 
Date: 
20 May 2020
Reviewer's report:
Thank you for sending me this paper to review. It was an enjoyable read and fills
an important gap in understanding of women's sexuality in conservative and
gender inequal cultures. 
The silent suffering of the women interviewed comes
across powerfully.
I thought the plain English summary was very good and much more 'meaty' and
interesting than the abstract, which lists the themes but doesn't give actual
results. Could the background and methods sections of the abstract be reduced in
order to leave room for some of the interesting findings described in the plain
language summary? Sentences such as 'This study is part of..' don't seem
particularly crucial.
Introduction. 
The authors argue that instruments are primarily clinical and omit
relational/situational dimensions. There are some papers that describe multi-
dimensional measures for non-clinical samples. E.g.
Mitchell (2013) Sexual function in Britain; findings from the third national
survey of sexual attitudes and lifestyles. Lancet 382 (9907) 1817-1829
Methods
The description of the qualitative methods did not always feel authentic. There
was heavy use of jargon to justify/explain strategies that, to me at least, seem
quite usual for qualitative research. 
For instance, the direct contact with
participants was needed to 'deconstruct the complexity inherent to sexuality', but
nearly all primary qual research involves direct contact with participants. It is not
clear how recruiting from clinics and 'working organisations' leads to 'holistic
and non-medicalised' understanding - would this not mostly come from the types
of questions asked in interview and the approach taken to analysis or 'producing
knowledge'? 
It would be good to use more straightforward language to describe
what was done. 
On page 7, from line 42-ish - the description of challenges with recruitment is
interesting but becomes quite discursive. Could some of this move to a
limitation section in the discussion part of the paper?
What is a 'working organisation'? Can you give an example?
Were women really selected purposively (beyond meeting eligibility criteria)?
From the description of the recruitment challenges, it sounds like the authors just
had to take women coming through clinic who were willing to be interviewed
and met eligibility criteria? If purposively selected, then how was this done?
How did you ascertain whether the women met the criteria?
Was the identification process the same for individual and group interviews?
The text on snowball sampling was unclear to me. Did this involve asking
participants to nominate others? And if yes, on what basis was this nomination
made? Was the snowball method just employed for the focus groups? Were fg
participants known to each other?
Did you really stop at a point of data saturation, or did you stop for pragmatic
reasons, when no further participants could be interviewed within the
timeframe/resources? (if the latter, that is fine and realistic, but I think good to be
clear)
Section on data analysis is nice and clear.
It's just a language thing, but I'm not sure transferability can ever be 'ensured',
although steps can be taken to increase the potential transferability….. The word
'ensured' is used quite often; I think the authors could be more circumspect here..
Results
I thought the results were clearly structured and easy to follow. The accounts felt
authentic and the quotes nicely illustrated the points being made and were
powerful in themselves. 
The authors could do more to clarify whether quotes come from individual
interviews or focus groups, and some comment on how, within groups, the
dynamic produced/shaped the accounts (was there agreement, censorship or
judgement at times, empathy, co-production of knowledge?)
A table summarising participant characteristics would be helpful and the tags for
quotes could give age range and marital status and also sexual difficulty
diagnosis if relevant. 
Some text missing (a quote?) after page 12?
Discussion
I felt the discussion was a bit rambling and lacked a clear structure. I found it
difficult to connect the paragraphs in the discussion to the themes in the results.
I think it would be good to be careful not to oversimplify the complexity
presented in the results. For example the sentence, 'Due to the lack of awareness,
more than half of the women in the study were sexually gauche at marriage and
had unpleasant sexual experiences' yet results speak to multiple reasons for
unpleasant experiences beyond just lack of awareness. Similarly, what is
'inappropriate communication'?
There were also a few statements that seemed neither supported by the results or
backed up by literature e.g. 'Assuming different roles as wives, mothers and
workers may overload women and affect their sexual interest.'
Some sentences were very long and hard to follow e.g. 'Not attributing sexual
symptoms to themselves might affirm the sociocultural conceptualisation of
menopause [5], long-term relationship with the husband [46, 47] and other
sociocultural factors [3], it reveals that women
‟
s 
shyness and their incapacity to
affirm their sexual-self prevent them from declaring their sexual difficulties. It
also reflects the husbands
‟
 centrality in women
‟
s sexual life that was apparent in
the findings. 
The limitations section should include something on the sampling strategy and
bias towards type of women willing to be interviewed. There are hints that these
are educated women but this is not explicitly discussed. 
The study ends with some rather generic recommendations. It would be good to
see these more tailored to the specific findings of the study.
Some smaller points:
'Many of these women were in their thirties and highly educated' - but sample is
described earlier as women aged 40-55?
What does sexually gauche mean?
Some other refs that could be of interest to this paper:
Brotto (2014) Narratives of desire in mid-age women with and without arousal
difficulties, Journal of Sex Research
Graham (2017) What factors are associated with reporting lacking interest in sex
and how do these vary by gender? Findings from the third British national survey
of sexual attitudes and lifestyles. BMJ Open 7(() e016942
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.
Not relevant to this manuscript
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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