Title: Characteristics of Chinese women in need of enhanced sexual health attention and at risk
of hypoactive sexual desire disorder
Version: 0 Date: 19 Feb 2023
Reviewer's report:
This study reviewed characteristics associated with sexual health-related attitudes, behaviors,
and symptoms that may prevent Chinese women from seeking help related to their sexual health.
The authors point out that past research has often conflated low sexual desire with hypoactive
sexual desire disorder, obscuring the heterogeneity of women’s experiences with sexual desire–
a very important consideration—considering the breadth of reasons women may experience low
sexual desire. While the authors have addressed an important topic, they need to better clarify the
scope and purpose of the paper in the introduction section and summarize how the findings from
their research questions are linked in the discussion. Further, there are some methodological
considerations in terms of statistical analysis that the authors should make (i.e., is there a better
way to examine their questions).
Abstract
1. In the background section, the authors refer to Chinese women’s “barriers to sexual health-
seeking behaviors.” However, constructs of interest are not labeled like this in the introduction.
Bringing this categorization into the introduction could clarify the purpose of the research.
Introduction
2. The introduction begins with a discussion of sexual communication between partners, which
suggests that sexual communication is of primary interest in this paper. However, the paper
centers around Chinese women’s overall sexual health, of which sexual communication is one
aspect. The authors need to first convey to the reader why it is important to study Chinese
women’s sexual health, specifically with the constructs they included and in the way they
examine these constructs.
3. The authors address the conflation of low sexual desire and HSDD; however, they do not
clarify why this is a problem, which is an important theoretical component of the research. Is it
about whether they are distressed by their low desire? Is it about whether they meet the criteria
for HSDD? Is it about what caused their low desire?
4. The authors should identify the overall purpose of this study. Currently, the scope seems too
large without identifying the overall reason for the four hypotheses. Further, there is not enough
in the introduction to justify the hypotheses.
Methods
5. Did the authors ask about current/past sexual behavior of the participants? These factors would
influence sexual attitudes, desire, etc.
6. It is unclear why the authors converted age into a categorical variable – what was the
theoretical justification? In particular, 25-64 is a large range in which sexual behavior and
attitudes may change drastically.
7. What justification do the authors have for the sexual attitude questions they asked? Were they
tested? In particular, people are routinely incorrect about how knowledgeable they are about sex
— so really, this item would be participants’ perceptions of their sexual knowledge. Further,
someone with low sexual knowledge may have more difficulty answering these questions. Did
the authors define “sexual health-related testing,” “sexual health problems,” or “sexual health-
related disorder” for participants?
8. What variables were included in the authors’ multiple imputation model? See https://
stefvanbuuren.name/fimd/sec-reporting.html for best practice guidelines for reporting multiple
imputation to replace missing data.
9. Why did the authors use dichotomized versions of their variables in the binary analyses? They
could have conducted regression analyses instead. What level of significance did they use?
10. The authors should describe their primary analysis in more detail.
Results
11. The first two paragraphs of the results should be in the methods.
12. The authors should describe the characteristics of the sample.
13. It may be better for the authors to refrain from the “risk factor” and “protective factor”
wording. It does not make sense to refer to “having a full understanding of sexual health
knowledge” as a risk factor for sexual shame or “thinking that sexual health testing is not
necessary,” or “thinking that treatment for sexual health-related disorders is not needed at all”
as protective factors against sexual shame. That would suggest we should prevent women from
gaining sexual health knowledge or viewing sexual health treatment as positive to prevent them
from having sexual shame. Further, we do not know the direction of this relationship.
14. The choice of analyses is confusing. The hypotheses are written in a way that suggests
analysis using structural equation modeling, given hypothesized relationships among the
variables. Further, there does not seem to be any theoretical backing to the variables examined.
Most of these variables were not described at all in the introduction. With such a large sample
size and range of variables, it would be unlikely not to see a relationship between some of them,
to the point it raises concerns about p-hacking.
Discussion
15. The authors state on page 11 that their findings regarding Chinese women’s willingness to
communicate align with the health belief model. However, the health belief model is focused on
perceived susceptibility/severity, motivation, and benefits/barriers. Their findings seem more in
line with the social ecological model since they show that environmental factors contributed to
women’s willingness to communicate.
16. The authors cannot state that their hypotheses were “confirmed,” as this can only be done
through multiple studies. It would be better for the authors to use “supported.” The authors also
must generally temper their conclusions throughout the discussion.
17. The authors state that living with friends was associated with higher shame on pages 11-12,
“The results were consistent with the interpersonal nature of shame.” However, the authors did
not assess the participants’ friends' thoughts about sex. It is possible that those living with friends
are also having sex outside of “acceptable” social boundaries and thus experience shame, unlike
women living with a husband having sex in an accepted manner.
18. Why do the authors reference the DSM-IV on page 15? The DSM-V has now been available
for 10 years.