Reviewer's report
Title:The differential impact of forced sex and sexual coercion on Chinese
women's mental health: a prospective cohort study
Version:1Date:26 February 2014
Reviewer: Amy Hammock
Reviewer's report:
Review
Manuscript Title: “The differential impact of forced sex and sexual coercion on
Chinese women’s mental health: a prospective cohort study.”
While I applaud the effort to shed more light on both (a) the association between
intimate partner sexual assault/coercion and mental health, and (b) the
contextual, cultural experiences of Chinese women who experience intimate
partner sexual assault/coercion, there are several issues in this manuscript that
must be addressed before it can be considered for publication.
Major Compulsory Revisions
(1) A central assumption in this paper is that there is something qualitatively
different between physical sexual assault in a relationship and sexual coercion in
a relationship--and that these experiences can be analytically separated from
each other. However, as you point out in the Background section (p. 4), sexual
assault is more commonly understood as occurring on a continuum. Thus, it may
be inaccurate to divide the experience in this way. Indeed the findings from the
qualitative data suggests that sexual coercion is part of physical sexual violence,
and that it worsens over time, rather than that it is an analytically distinct concept.
As the whole paper hinges on this distinction, it makes sense to explain more
completely why it is important to distinguish between these two phenomena and
if, indeed, it is possible to separate them analytically.
(2) Related to (1), a very important piece of information that is currently missing
from this paper is data about how long each respondent was in the abusive
relationship. It is likely that there might be differences in the length of time they
have been with their partners. If this is true, it is possible that some women’s
experiences of non-physical sexual coercion are, in fact, reflective of the amount
of time that they have been with their partners, and that if they were to stay in
those relationships, they might begin experiencing physical sexual assault over
time. This would suggest that physical and non-physical sexual assault are not
really such different experiences--just a continuum of experiences. Is there
information on the duration of the intimate relationships under examination?
(3) Currently, the qualitative portion of this manuscript is under-developed.
Indeed, the manuscript as it stands now does not provide adequate justification
for why there is use of both types of methods. The qualitative and quantitative
data, though on the same subject, do not really seem to complement each other
as much as they could. Please describe more completely what the qualitative
data are being used for and when in the research design the qualitative
component came to be. Is a Quant-then-Qual design, a Qual-then-Quant design,
or a simultaneous design? The way it is described now it sees as though it is a
simultaneous design, but that it is not clear what the additional qualitative
interviews are adding to the research endeavor as a whole. Is the qualitative
portion being used to substantiate the quantitative findings? Add
complexity/richness? Right now, the story seems to be quite similar with both the
quantitative and qualitative data. One way to substantially improve the qualitative
section would be to provide data (i.e., quotations) to substantiate the findings.
Quotations in the interviewees’ own words are crucial when reporting qualitative
findings; it is in these data that the richness and nuance of the story will be found.
(4) The sampling described in this paper is very confusing. Was this part of a
larger study that was both quantitative and qualitative? Or was the quantitative
part of one study, and the qualitative part of another? How were the
“non-abused,” “abused” women selected out of that sample? Please see my
more detailed questions about sampling below, in the page-by-page feedback.
(5) Many of the qualitative interview questions are close-ended, which is not
standard practice for qualitative methods—because close-ended questions do
not usually generate discussion. How did this work differently in your study? On
page 15 you reject the hypothesis that sex can be used by the partner to “make
up” after a violent event. Was this experience asked about in the interviews? If
not, how do you know that such sex did not happen? In general, need to make
an analytic distinction between (1) perpetrators’ intentions/behaviors and (2)
women’s interpretations and experiences of perpetrator behaviors.
(6) In general, qualitative data analysis needs to be described more completely.
This section describes using “purposive sampling” (out of 200) to select 20 cases
that have a wide range of experiences with the phenomenon under study. Clarify
the sample: Who were the original 200 respondents? Were these 200 interviews
transcribed? Have said you used “purposive sampling” out of the 200
respondents, you selected “20 CASES.” Where were the 200 respondents from?
How were the data analyzed? A priori, with the two groups? Or was it emergent?
If themes were emergent, need to describe that process better. You start out a
priori dividing your qualitative data analysis into two types (sexual coercion &
penetrated rape). What, if instead, these groups are mutually exclusive, and
instead one is a subset of the other? Must show how the qualitative analysis
distinguishes between these two possibilities.
Minor Essential Revisions
p. 2
-- end of Background section: “compare” should be “comparing.”
p. 4
First paragraph
--clarify: “few have examined sexual assault as separate from physical violence.”
Do you mean that the two concepts have been lumped together under “physical
violence”? or that sexual assault has not been asked about? Be more specific.
p. 6
Participants and Settings
--What percentage of the population are “unable to communicate in Cantonese or
Putonghua” and thus were excluded?
Quantitative Component
First sentence
This part on sampling is confusing. There needs to be much more description
about “the larger study” that you reference in this paragraph. How many were in
the larger study? Who were they? Why were 745 women extracted from that
larger study for this particular study? (i.e., why not use all the data available?)
Were the woman in this subset of 745 similar to those in the larger study on key
demographic characteristics?
p. 7
Last sentence, first paragraph: You give examples of behavior-specific items to
determine if psychological/physical/sexual abuse occurred. Given that this is a
paper specifically about the difference between physical sexual assault and
sexual coercion, clarify which of these items on the scale are used to determine
which of the behaviors (physical sexual assault or sexual coercion).
Last paragraph, first sentence: instead of “and that by the partner,” revise to “and
those of the partner.”
p. 9
First paragraph: I imagine it was not really possible to ensure that “no distress or
harm had been caused.” Perhaps change this to “minimal distress or harm.” Also,
you say that referral or intervention was provided where appropriate. Does this
mean that only some women were given resources or referrals? How was it
determined that the respondent might need such referrals. Sometimes, it is not
immediately obvious who needs referral, so we give a list of resources to every
respondent. Did you do some sort of similar universal intervention such as this?
Qualitative Component: Must describe much more clearly who was interviewed
and their relationship to the quantitative study. Was the sample of women who
completed in-depth interviews from the same larger sample that the quantitative
survey respondents came from? If so, were women interviewed (in-depth) at the
same time as they answered the survey questions? If not, how were they
recruited to participate? How did you ensure that you were purposively sampling
appropriately?
p. 10
First paragraph. Many of these questions are not very qualitative in nature, as
they are close-ended rather than open-ended (i.e., has your partner ever made
you feel uncomfortable in your sexual relationship?, “Has he ever pressured you
to have sex when you didn’t want to?”). Qualitative interviews should be
designed to elicit descriptive responses from the interviewee.
Second paragraph
--You say you used a particular technique for eliciting information from Chinese
women. Name and describe this technique. How is it different than other
qualitative interviewing techniques of exploration, validation and
acknowledgement?
--you say that 200 interviews were conducted in the larger study. What larger
study is this? The one you spoke about earlier? How were these women
recruited? Were they the same women in the larger quantitative study? (How)
were they compensated?
Third paragraph
--You say that you used “purposive sampling to select sample members using
typical case sampling.” This is confusing. Were you using typical case sampling
or purposive sampling? It seems that purposive sampling may have been used to
establish the 200 women sample (I say may have, because I’m not sure whether
or not the sample was purposive), and that typical case sampling was used to
select the 20 cases from among these 200. Is that what happened? This part
needs to be clarified.
--Your discussion of saturation is also a bit loose. Do you mean that you selected
the 20 person sample and then analyzed the data until saturation, or that you
analyzed the data after every case was selected, and determined that you had
reached saturation once you had picked an analyzed 20 cases? Depending on
what analytical approach you use (grounded theory, narrative analysis, etc.), it is
usually typical to have an initial sample that is analyzed, and then, depending on
if saturation has been reached, recruiting more respondents in a purposive
manner. In this case, if I’m understanding the larger sample clearly, all the data
was already collected before analysis began…
End of 10, beginning of 11
--Need more detailed explanation of the data analysis strategy and approach.
Right now, you say that you engaged in repeated reading, intuiting, analyzing
and synthesizing. These are all very different activities, with particular
approaches associated with them. What specific strategy did you employ first?
Second? Third? Was a computer-assisted qualitative data analysis software
used?
p. 13
Forced sex by a violent intimate partner
--line 4: “threatened with weapons, or beaten up if refused to have sex” should be
“…if they refused to have sex.”
--line 8-10: you talk about how these forced sexual acts were accompanied by
degradation, demeaning sexual acts, derogatory remarks, and public humiliation.
How are these analytically distinct from the sexual coercion language and
behaviors that you spoke about above? It seems that things like degradation,
derogatory remarks, etc. come with sexual assault of any type, even IPV of any
type… what makes this qualitatively different?
p. 14
Second full paragraph
--“may have increased women’s susceptibility to violence and worn down their
resistance.” This language suggests that the phenomenon that is being
described may be one of length of time in the abusive sexual relationship, rather
than only a difference of physical sexual assault versus sexual coercion.
Third full paragraph
--‘personal risk management strategy needs a “ ‘ “ at the end of it. Also, I’m not
sure you can say that the women experiencing sexual coercion are engaging in
personal risk management strategies where those experiences physical sexual
assault are not….It may very well be a personal risk management strategy to
react the way they do to the extreme sexual violence they are experiencing.
p. 15
First full paragraph
--“In light of the humiliation and degradation used by the perpetrators.” Clarify.
The humiliation and degradation were what the woman described experiencing at
the hands of their perpetrators – not the other way around.
--you say that it is “inconceivable” that the latter explanation could apply. I do not
think you have shown evidence to support this claim. It is not clear from the
interview questions asked (detailed on p. 10) or the analysis presented, that “sex
as apology” was even discussed or asked about during the qualitative interviews.
Instead, the interviews focused on instances when the partner made the
interviewee feel pressured or uncomfortable about sex.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, but I do not feel adequately qualified to assess the
statistics.
Declaration of competing interests:
I declare that I have no competing interests.