Title: Self-experienced sexual and reproductive health in young women with Attention Deficit
Hyperactivity Disorder A qualitative interview study
Version: 2 Date: 11 May 2022
Reviewer's report:
Summary:
This manuscript explores sexuality, motivations for sexual activity, and sexual relationships in a
sample of women with ADHD. The authors should be commended for their work on a relatively
understudied topic. I include multiple suggestions below that will strengthen the manuscript,
which at present is not focused, lacking key methodological details, and in need of English
language editing.
Abstract:
- Consider specifying why “sexual exploration can be a challenge for young women with
ADHD”.
- The results section mentions “being young and inexperienced” as factors that contribute to
insecurity during sex. These factors are certainly not specific to women with ADHD. How
does a diagnosis of ADHD exacerbate or contribute to these challenges? Increased detail in the
results section that draws attention to the ways in which the theme of “feeling sexually secure”
specifically connects to ADHD would be useful.
- The conclusion focuses on “sexual risk-taking” and “negative outcomes”, which are not
mentioned or clarified in the results section. New content areas, especially “sexual risk-
taking” (which is nuanced and has multiple possible associations depending on context), should
not be introduced in the conclusions section.
- In the second sentence of the conclusion, the authors state, “It [presumably the study]
acknowledges the need for understanding and acceptance by peers, contributes strategies to
improve sexual relationships…” These strategies are not mentioned in the results, and this
implies that the women who were interviewed “contributed strategies” to improve sexual
relatonships. Were they asked about strategies in the interviews? Or are the authors generating
suggestions for strategies based on the content of the interviews?
Introduction:
- Pg. 3, lines 54-57: I would expand on the description of these challenges. Doing so would
strengthen the rationale for this paper.
- Pg. 4, lines 79-81: Please rephrase for clarity (“…when having several sexual partners”).
- Pg. 4, lines 87-88: Please include a reference for the following sentence: “Among college
students…”
- Pg. 5, lines 101 to 103: Sexual health and reproductive health are similar but distinct areas.
Up until this point, the introduction focuses pretty much exclusively on sexual health – sexual
risk-taking behaviors, sexual motivations, allusions to intimacy and sexual function – rather
than reproductive health. If reproductive health is to be mentioned and included here, what were
some of the key research questions and/or gaps in the literature around reproductive health in
this population?
- General comment: The introduction provides a decent overall summary of the main issues at
hand, but lacks specificity and detail. It seems that these interviews really did cover a range of
issues, but I would try to clarify the specific domains that were of interest (for example, sexual
motivation, sexual relationships, and sexual risk-taking) and organize the introduction around
those domains, reviewing what we already know and what we need to explore. Otherwise, the
introduction lacks cohesion and focus.
Methods:
- Pg. 6, lines 116-117: Please provide more details on the basic tenets of “reflexive thematic
analysis”. In addition, what specific choices were made in the adoption of a “constructionist
stance”? How did this stance affect the analytic approach? Please also provide a reference that
describes how constructionism can be integrated into qualitative data collection and analysis.
- Pg. 6, lines 119-140: By whom were these women diagnosed? Were diagnoses confirmed
by licensed clinicians? The authors note that “questions were asked about when and where the
diagnosis was set and by whom” to ensure the accuracy of the diagnoses, but were diagnoses
confirmed via follow-up? Example questions would also be appropriate to include.
- What was the target sample size? 18 seems low, given the complexity of the topics and
likely nuance. Was theoretical saturation assessed? If so, how? Reflecting on the data is not an
assessment of theoretical saturation.
- Pg. 7, lines 137-139: Please describe the nature of the purposeful sampling.
- Table 1: Please clarify in the text how the other psychiatric diagnoses were assessed or
confirmed. If they were self-reported, please indicate that they were self-reported.
- Pg. 9, lines 159-160: Please clarify the rationale behind including both individual interviews
and a focus group at this point in the Methods (i.e., that the intention was to have focus groups,
but participants felt uncomfortable, etc.). The difference in methodology should be identified
as a limitation of the study’s design – content generated in an individual interview may be
categorically different than content generated in a focus group, given group processes.
- Pg. 9, lines 162-165: After how many participants was it determined that the first question was
not effective? Please consider including a table with sample questions from the interview guide.
- Pg. 9, lines 171-172: Was the video feature of Zoom disabled such that participants just used
the “written chat forum”? Or was the written chat forum in addition to the video feature? Please
clarify.
- Pg. 11, lines 209-211: Please provide examples of the ways in which the data analysis was
“collaborative and reflexive”.
- How was the trustworthiness of the data assessed? What efforts were made to increase
trustworthiness?
Results:
- Pgs. 12-13, lines 245-251: There is a lot of content covered in this section, which few supporting
quotes, most of which doesn’t appear to fall under the broad category/theme of “acceptance of
being different”. Please consider breaking down these concepts into themes or subthemes that
are each represented by a sample quote. And it might make sense for the sake of clarity to take
out some of the subthemes (e.g., “living with intense emotions”) from the larger umbrella of
“acceptance of being different” and consider them as themes in their own right. It does not seem
women were necessarily talking exclusively about the acceptance of their intense emotions.
- Pg. 13, lines 260-261: Please clarify that the “self-destructive behavior” is sexual in nature.
Did women themselves describe these behaviors as “self-destructive”?
- Pg. 14, line 279: Is self-knowledge viewed as an aspect of acceptance? It certainly can be, but I
think there needs to be more clarity and explicit discussion of how each of these identified sub-
themes relate to the larger theme of acceptance.
- Pg. 14, lines 284-287: Please consider including a direct quote from a participate to support
these points.
- Pg. 14, lines 288-298: I appreciate the section on strategies, which certainly does speak to
acceptance, but that connection could be explicitly highlighted. More details (and/or more
quotes) that reference these strategies would be a nice addition.
- Pg. 15, lines 308-310: Is this editorializing on the part of the researcher? Or were these
comments made by participants? Please clarify.
- Pg. 16, line 337: “Comfort with sexuality” does not really capture the content presented in this
section. I would break down this theme into separate themes or introduce sub-themes.
- Pg. 17, lines 342-344: Please consider including a direct quote from a participate to support
these points.
Discussion:
- Pg. 20, lines 418-420: This summary does not capture the richness and nuance of the data.
Please consider elaborating.
- Pg. 21, lines 432-434: This sentence demonstrates a potential mismatch between the name/
title of the theme and its content.
- Pg. 23, lines 479-481: Was pressure from peers featured prominently in the results? This
paragraph seems slightly out of place -- especially at the end (lines 487-488), when the
conclusion focuses on risk for sexual victimization and re-victimization (content that is not
discussed in the paragraph or in the results).
- Pgs. 23-24, lines 497-499: This needs to be included in the methods, not the results.