Title: Characteristics of Chinese women in need of enhanced sexual health attention and at risk
of hypoactive sexual desire disorder
Version: 1 Date: 30 Mar 2023
Reviewer's report:
Thank you to the authors for the substantial reviews they have made in response to feedback
from me and the other reviewers. My main concern is that the paper is difficult to comprehend
due to the breadth of variables and analyses included—and I don’t know that including all these
analyses in one paper is justified. I provide more specific comments below, but I would advise
the authors pay particular attention to points 3-4 below.
Introduction
I appreciated the contextual information the authors added to the introduction regarding the
history of women’s sexual health in China, as well as the additional detail about the variables
of interest in the study. However, I had a few remaining concerns:
1. It may be preferable to organize the historical information in chronological order, as it
currently is a bit disjointed. The authors start with the first female sex clinic opening in 2009
but then jump back to the 1980s.
2. The authors should more clearly define what they mean by “locating the target population.”
While it seems that they are referring to women at risk of HSDD, the Health Belief Model (cited
by the authors) is used to explain health behavior. Thus, it would seem the focus is on identifying
women who do not seek help for sexual problems. The paper seems to conflate having HSDD
with not seeking help for HSDD symptoms.
3. The researchers use the term “psychological barriers” without clearly defining them. This is
a broad concept, and the relevant barriers differ based on the health outcome being examined.
Further, while the analyses in the paper focus on identifying predictors of these psychological
barriers (i.e., willingness to communicate, shame). However, the authors do not clearly justify
examining predictors of these psychological barriers in order to understand women who have
HSDD. How are willingness to communicate and shame connected to HSDD?
4. The authors should consider whether the analyses exploring psychological barriers and the
analyses exploring correlates of sexual distress and HSDD are well-suited to be addressed in a
single paper. Alternatively, perhaps the psychological barriers analyses should be conducted in
the subsample of women who report symptoms of HSDD.
Method
Thank you to the authors for providing additional information about their measurements and
analyses. I have a few questions about the new information provided, as well as some additional
questions that came up when I reread the paper.
5. Were all women in the study currently in a relationship? For women who were previously
married (widowed, divorced, etc.) was the question on length of relationship related to their
marriage or a current partner?
6. I have some concerns with the “shame” question, and I am not sure if these are due to
translation or how the question was actually phrased. In English, “it is a shame” is a colloquial
phrase, which basically means you wish the situation was different, or you are upset about the
situation. It does not necessarily mean you feel ashamed. If this was a problem in translation,
I would rephrase as “To what extent would you feel ashamed to be diagnosed with a sexual
health-related disorder?”
7. The authors used the mice package for single imputation. Is this a valid method? Mice does
allow for combining imputations into a single dataset (averaging across imputations using mean,
median, or mode depending on the type of variable), though even this is not the preferred method.
If only one imputation dataset was created, this would not necessarily produce the most suitable
datapoint for replacement. Is there a reason that the authors did not use the merge_imputations
function or, the preferred method, pooled analyses?
8. The average response time was less than 4 minutes. This still seems very short for the number
of questions included. Is this the response time prior to removing those who took less than 30
seconds? After excluding those with response time less than 30 seconds, what was the shortest
response time? What was the longest? How long did the authors expect the survey would take?
9. The authors clarified the reasons for dichotomizing their variables – however, it is unclear
why they only dichotomized when using the variables as outcomes but not when they were used
as predictor variables in the logistic regressions.
10. It is customary to use p < .05 (not less than or equal to) for significance level.
11. The authors revised their analyses to a stepwise backward regression in response to my
previous comment raising concerns about p-hacking. However, using this method of analysis
is not a remedy (see Smith, 2018 - https://journalofbigdata.springeropen.com/articles/10.1186/
s40537-018-0143-6; Livingston et al., 2010 - https://jamanetwork.com/journals/jamasurgery/
article-abstract/518707), and it may even obscure the variables that are important.
Results
Thank you to the authors for the additional information about the sample, as well as the revised
tables. These have greatly improved the ability to comprehend the results. However, I have a
few additional comments after reviewing the updated findings.
12. Some of the response categories are rather small (e.g., only 27 people were in the illiterate
category; widowed, divorced, separated categories have less than 100 people in each). Why
didn’t the authors collapse smaller categories?
13. Why did the authors report descriptive statistics for only a selection of the variables
measured? It would be especially helpful to report descriptive statistics for the main variables of
interest (willingness to communicate, shame). This is important for understanding how skewed
responses were and the size of the sample for each group.
14. How did the authors choose the reference groups for their variables? It is somewhat unusual
to use a midpoint as the reference group, and for ordinal variables, it does make interpretation
rather confusing.
15. Significance level can never be 0. The authors should report p < .001.
16. I have concerns about multicollinearity, especially in the correlates of shame analysis. Many
of the variables are likely highly correlated, particularly the marriage and living with variables
(you cannot live with a spouse if you are unmarried; if you are living with a spouse you are
unlikely to also be living with friends, etc.). Is there a reason that each of these living with
variables is its own binary variable rather than a categorical variable (lives with spouse/partner,
lives with friends, lives alone, lives with other family, etc.)?
17. I am not sure why the figures were included because they do not answer any specific
questions posed in the introduction. Further, the titles are confusing (sexual health knowledge is
the title but then the footnote says only panel A shows sexual health knowledge scores). There
is also a 15–19-year-old group in the age figures, but those under 18 were excluded – so this is
only 18 and 19 year olds, correct? Lastly, the authors dichotomized variables for their analyses,
so why do the figures use the full Likert-type scale?
Discussion
The authors clearly put substantial effort into revising the discussion and contextualizing their
findings. However, the discussion is too lengthy and spends an inordinate amount of time
describing the results. Further, the authors need to temper their claims and base any claims
or interpretations in past work. I did not have sufficient understanding of what findings were
important or how the findings could be used practically. Below are a few more specific
comments:
18. I previously made a comment about the authors’ use of confirmed regarding their hypotheses.
However, the term “verified” which has been used as a replacement in some areas presents the
same problems.
19. Why do the authors report on findings with a p-value of 0.06 in the results? Not only is
this not significant based on their reported p¬-value, but education is likely confounded with
age and marital status, which were removed from the model with the stepwise regression.
Further, the comparison group seems arbitrary – all that this would show is that there was a
nonsignificant trend toward lower willingness to communicate among women with postgraduate
degrees compared to women who only had a junior high level of education. Further, it is unclear
why the authors suggest weakness of sex education as the reason for this potential association
(why would those with a postgraduate degree have worse sex education than any other group?).
20. The citation for Ma’s study (page 19) should be included.
21. On pages 20-21, the authors state: “The main driving force for people to seek medical
services is the severity of these diseases and the benefit of treatment. However, when it comes to
sexuality, women’s concerns about how they will be perceived by others have a greater impact
on communication.” What evidence do they have for this statement?
22. The authors do not discuss the possibility of sex education differences in relation to city
of residence; however, this seems like a situation in which sex education would be important
(if sex education varies by city). Further, the difficulty the authors have with the interpretation
there is precisely the problem with including too many variables in models – it results in limited
interpretability.
23. The authors state on page 22: “Shame is the biggest psychological barrier impeding Chinese
urban women’s sexual health-seeking behavior.” What evidence do they have for this?
24. The authors state on page 23 that their findings “suggested that women who underestimated
the susceptibility and severity of sexual health-related disorders, as well as the benefit of
treatment, were less likely to experience related shame.” However, both women who thought
testing was unnecessary and those who thought it was very necessary had lower shame. Further,
those who thought sexual health problems were “not very common had lower shame than those
who though they were common, but there was no difference between those who thought SH
problems were “not common” and those who thought they were common. So, the authors’
statement does not always hold true.