Reviewer’s report
Title: 
Middle-aged Lebanese women interpretation of sexual difficulties: A
qualitative inquiry
Version: 
0 
Date: 
24 Jun 2020
Reviewer's report:
The manuscript entitled "Middle-aged Lebanese women interpretation of sexual
difficulties: A qualitative inquiry" was a very interesting read and provides
important new findings on the sexuality of mid-life women in Lebanon
specifically but perhaps on women in the middle east as well. It was excellent to
see that attention was placed on middle aged women, however, the verbatim of
women and the discussion of the authors did not present much information at all
on aging, the perception of the role of age on sexuality, the evolution of sexuality
over time … Overall, excellent contribution with a few caveats outlined below:
Plain English summary; it is my understanding that the BMC Women's Health
does not use such summaries.
Introduction:
Excellent introduction; parsimonious but covering the key literature. 
I understand that there is a parsimony of research on mid-life women's sexuality
in middle East countries. However, I doubt there is only one (referenced); I
would appreciate an extension of the introduction to include some information
on sexuality in Lebanon - or extend the reach to similar countries. I also expect
that attitudes differ significantly within the Lebanese population depending on
cultural/religious background…. Or does it? Any information available. This
would be important information to glean to appreciate the findings. 
For example, many of the accounts of women speak to male sexual dysfunction.
It may be good to inform the reader of male sexual dysfunction - and women's
dysfunction prevalence rates (e.g., Laumann's work, or that of regional
researchers). 
Method:
I believe the headers need to be slightly adjusted; level 1 header is not in italics. 
" This paper that aims to explore women
‟
s construction of their sexual
difficulties is part of a
programme of work that focuses on women
‟
s sexuality." This is an interesting
statement but with insufficient information… which program focusing on which
aspects (in which group, middle-aged women?). The term 'women's construction'
also seems inappropriate. I assume that you mean to touch on women's
perception of their sexuality and how they construct meaning or definitions of
dysfunction, problems… (?)
p. 6: "It is a qualitative study guided by an interpretive inductive process,…"
please use a comma between interpretive and inductive as they are two separate
processes. 
p. 7: What are "working organizations"?
"The first investigator of the study (MA) was involved in the recruitment
process." … how so? 
Please rephrase in general language: "Some gave me more than one appointment
but in vain"
How what the following determined: "Women who had acute or chronic physical
and mental health problems at the time of the interviews were excluded."
How was informed consent obtained.
No mention of various institutional Research Ethics Boards approving the study
(or an academic institution REB that may apply to recruitment settings). 
Three methods are included in data collection: individual interviews, focus
groups, and written materials. Please discuss in more detail the rationale for
choosing various approaches and the implications of the medium of collection to
the information obtained. 
The focus groups need to be described; how many women per group, how long,
where did the groups take place, prompts used (other than scenario), who let the
groups, etc.)
What does this mean? "Reflections, impressions and preliminary interpretations
were added.
What does the following mean… it may be clarified if you describe how the
analysis was performed between various members of the research / author team -
how you worked together exactly (did everyone speak Arabic): "The translation
of data into English was done at the level of the thematic chart to preserve the
cultural meaning conveyed by the language and the implications this might have
on the accuracy of findings." And "The three authors worked together to agree
the coding and analysis process." The latter is too vague….
p. 10; perhaps chronicity instead of: 'sustainability'
The qualitative accounts are quite sobering and the women describe quite
unhappy sexual relationships, to say the least. It would be really important to
provide perspective for this. How were women approached, what were they told
in the recruitment add/text/verbals, did they expect to talk about their sexuality
or their sexual problems or both, etc….? 
Results:
Personally, I did not find Table 1 effective or necessary but I defer to other
reviewers and the editor. 
I was struck by the immediate dive into specifics…is there a way by which the
authors gleaned an insight to overall satisfaction - or dissatisfaction with
sexuality for this group of middle aged women. The results discuss problems…
was this specifically prompted. After all, at the end of the introduction, the
authors express an intent to investigate meaning, experiences and concerns: "…
Its aim is to present a narrative analysis of the meaning and experiences of
sexual concerns and difficulties from the perspective of middle-aged Lebanese
women." 
p. 13: "They also accused him of selfishness and forced anal sex describing this
sexual behaviour as unpleasant and illegitimate." This may have to be re-written
to be clear. Women accused male partners of selfishness… 
Discussion:
The discussion starts with the following sentence: This study explored the
meaning of sexual difficulties for the middle-aged Lebanese women drawing
upon individual and focus group interviews."
I believe the purpose of the study can be tightened up more. Meaning was
discussed but is somewhat mixed - perhaps inextricably linked to perceived
cause. It may be helpful to clarify this. 
p.21: "women in the study were sexually gauche at marriage" what do the
authors mean to express with this? Inexperienced? Awkward? … 
Likewise: "Women
‟
s poor language of sexual-self" not clear
I believe that the following sentence is problematic: "Although she is a
psychologist, she associated her problem to a biological cause amenable to
medical treatment and dismissed that „it was all in her head
‟
 as she realised after
two years of suffering." While these may be the participant's words, the sentence
is written to read as if the authors agree with the 'all in the head' statement.
Vaginismus is not all in the head; while psychological factors are - as in all,
central, there are physiological aspects that need to be addressed via pelvic floor
physical therapy, progressive dilatation, etc. - or via the psychological
intervention of massed exposure of vaginal penetration exercises with a therapist
present. Not to mention a careful assessment to identify potential physiological
causes for pain (e.g., PVD, hymeneal abnormalities, etc.). 
p.22: "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]…" how so? In addition, it is unclear what sociocultural
conceptualisation of menopause the authors refer to as there are many…
Limitations:
- Should include that data was collected via different means (focus group,
interviews) but analyzed collectively
- Translation of qualitative data needs to be acknowledged as a limitation
The overall quality of writing in this manuscript is inconsistent and could benefit
from further editorial changes. Some of the verbatim reports of women are
poorly written and it is unclear whether this reflects the original statement in
Arabic. It this is not the case, it may be good to edit the statements - staying true
to content but elevating the sophistication of grammar and syntax. 
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No
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Yes
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
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