Dyadic Satisfaction and Shared Affectivity Are Associated with Psycho-Sexual Functioning in Elderly Men and Women

Round 1

Reviewer 1 Report

The article presented is of enormous interest and relevance. It is worth paying attention to sexual well-being in the elderly. Usually, studies on sexuality have focused more on the young adult population than on older people.

The proposal presented, moreover, has an extremely interesting approach and the methodology is rigorous and of high quality.

Some aspects that would be worth revising. 
The objective should be specified more clearly. Theoretical interpretations should be left for other sections. 
The authors should explain in a clearer way the small sample of women in the study. And how this aspect can alter the significance of the results. Likewise, it should be specified where the sample was obtained from. That is, how the process of recruiting the subjects participating in the study was carried out. 

 

Author Response

The article presented is of enormous interest and relevance. It is worth paying attention to sexual well-being in the elderly. Usually, studies on sexuality have focused more on the young adult population than on older people.

We would thank the Reviewer for recognizing our effort to study sexual wellbeing of elderly people.  

The proposal presented, moreover, has an extremely interesting approach and the methodology is rigorous and of high quality.

Thank you very much for your appreciation.

Some aspects that would be worth revising. 
The objective should be specified more clearly.

We would thank the Reviewer for her/his comment. The study objectives in the abstract have been clearly specified as follow:

Abstract:

“Hence, we aimed to evaluate the impact of specific psycho-relational variables, such as intimacy, increased affective gestures towards partner (AGtP), daily shared activities and dyadic satisfaction, and on the psycho-sexual wellbeing of elderly people, expressed in terms of sexual pleasure and sexual functioning.”

Theoretical interpretations should be left for other sections. 

We would thank the Reviewer for this suggestion. Theoretical interpretations have been deleted from the abstract.

The authors should explain in a clearer way the small sample of women in the study. And how this aspect can alter the significance of the results.

We would thank the Reviewer for this comment. We take the subjects, selecting only those declaring sexual activity during the lockdown, from a broader sample of subjects, who have been recruited for a study evaluating psycho-emotional and sexual well-being during the COVID pandemic (and lockdown). Unfortunately, elderly women who agreed to participate at the study, and who declared to have been sexually active during the lockdown were few. For this reason, we decided to study only perceived orgasmic intensity as a dependent variable in association with several other independent variables (please, see page 9, first sentence of the results). We completely agree with the Reviewer opinion that this aspect may represent a limitation. Hence, this limit has been yet inserted in the discussion of the manuscript (please, see the limits at the end of the discussion).

 

Likewise, it should be specified where the sample was obtained from. That is, how the process of recruiting the subjects participating in the study was carried out. 

We agree with the Reviewer’s comment about the importance of describing the recruitment process. However, this information was omitted since the complete procedure has been previously reported in another yet published study (please, see the reference 19). In the text, section “Methods” we have now better specified this aspect.

 

 

Author Response File: Author Response.doc

Reviewer 2 Report

The authors report data from an online survey, meant to investigate psychological and relational factors connected with sexual health in elderly people.

The English of the manuscript is often hard to follow; I do suggest the authors to have their work revised by a native mother-tongue English speaker.

I could not find the approval of an Ethical Committee, which is for sure needed for this kind of study.

The tools used were not developed to be applied online. This could have changed their psychometric properties. How was this issue managed, since no control group was recruited?

The statistical analysis is difficult to follow.

The authors state that "The normal distribution of the variables was assessed through the Shapiro Wilk test. A p value greater than 0.05 was considered as an efficient value for the normal distribution of the data": this is not exactly the same as saying that eh Shapiro Wilk test refuses the null hypothesis (i.e. the variable is normally distributed) if p>0.05.

"Non-normally distributed variables were represented as medians with
the 95% confidence interval": do the authors mean 5-95% confidence interval?

Why was ANCOVA used? And anyway, it does not assess the impact of one variable on another variable; it allows to see if the dependent variable changes when the independent variable does, controlling for covariates.

Why were two corrections (Bonferroni and Tukey) used?

How was the direction of the relation between the variables established? To make an example, the authors imply that an increase in the amount of time devoted to shared activites reduces the possibility to have a positive sexual interaction; however, data could be read to imply instead that a reduced sexual interaction leads to an increase in shared non-sexual activities.

Some data are reported with two decimals, some others with one decimal (which I think is the best choice).

Was a priori power calculation conduted? How or why not?

A comparison between two groups is meaningless if one group is five times as large as the other (males:females in this study).

 

Author Response

Reviewer 2

The authors report data from an online survey, meant to investigate psychological and relational factors connected with sexual health in elderly people.

The English of the manuscript is often hard to follow; I do suggest the authors to have their work revised by a native mother-tongue English speaker.

We would thank the Reviewer for her/his comment. The manuscript has been now completely revised by a native mother-tongue English speaker.

 

I could not find the approval of an Ethical Committee, which is for sure needed for this kind of study.

The approval of the Ethical Committee has been voluntarily omitted, due to the necessity to maintain anonymity. However, here attached is the sentence present in the methods section where we specify that ethical committee approval has been obtained.

“The institutional ethic committee of the XXX approved the protocol.”

 

The tools used were not developed to be applied online. This could have changed their psychometric properties. How was this issue managed, since no control group was recruited?

Respectfully, we disagree with the Reviewer’s opinion. Psychometric tools, and questionnaires are in general very often shifted from the printed version to the online version, to provide for several limitations due to specific condition, or due to the difficulty in obtaining data about specific arguments. This was also our case. In fact, due to the specific historical period and due to social limitations related to the COVID pandemic, we decided to create an online version of the questionnaires. Then the survey was uploaded to a dedicated website. We are almost sure, also based on literature evidence, that obtained data reflect the real picture of the subjects’ psycho-emotional and sexual wellbeing during the lockdown phase (please, see Kramer et al., Strategies to address participant misrepresentation for eligibility in Web-based research. Int J Methods Psychiatr Res. 2014 Mar;23(1):120-9. doi: 10.1002/mpr.1415. Epub 2014 Jan 16).

 

The statistical analysis is difficult to follow.

The authors state that "The normal distribution of the variables was assessed through the Shapiro Wilk test. A p value greater than 0.05 was considered as an efficient value for the normal distribution of the data": this is not exactly the same as saying that eh Shapiro Wilk test refuses the null hypothesis (i.e. the variable is normally distributed) if p>0.05.

We would thank the Reviewer for this specification. The manuscript has been amended.

 

"Non-normally distributed variables were represented as medians with
the 95% confidence interval": do the authors mean 5-95% confidence interval?

In this study we represented medians with the 95% CI following the standard interpretation. Hence, we supposed to have had 95% of probability that our data contained the true mean of the population, and to have had 5% of probability to commit an error. Due to the adoption of the usual interpretation, respectfully about the Reviewer’s comment, we believe that there is not the necessity to explain this interpretation in the text.

Why was ANCOVA used? And anyway, it does not assess the impact of one variable on another variable; it allows to see if the dependent variable changes when the independent variable does, controlling for covariates.

As the Reviewer suggests, we performed the ANCOVA to assess the differences among some means related to specific independent variables. We changed the text about the ANCOVA accordingly (please, see the statistical analysis and results section).

 

Why were two corrections (Bonferroni and Tukey) used?

We would thank the Reviewer for this comment. We adopted only the Bonferroni correction. Unfortunately, the mention of the Tukey test represents a typo. We have deleted this information from the revised manuscript.

 

How was the direction of the relation between the variables established? To make an example, the authors imply that an increase in the amount of time devoted to shared activites reduces the possibility to have a positive sexual interaction; however, data could be read to imply instead that a reduced sexual interaction leads to an increase in shared non-sexual activities.

As suggested by the Reviewer, we can interpret the association between two/several variables in almost two ways: the first one is the statistical interpretation, which cannot give the possibility to know the “real direction of the relation between the variables”. The other one interpretation is an inference, based on what we know from literature (see for example: Symonds, T., Roblin, D., Hart, K., & Althof, S. (2003). How does premature ejaculation impact a man’s life? Journal of Sex & Marital Therapy, 29, 361–370;     Porst, H., Montorsi, F., Rosen, R. C.,Gaynor, L., Gruppe, S.,&Alexander, J. (2007). The Premature Ejaculation Prevalence and Attitudes (PEPA) Survey: Prevalence, comorbidities, and professional help-seeking. European Urology, 51, 816–824; Burri A, Radwan S, Bodenmann G. The Role of Partner-Related Fascination in the Association Between Sexual Functioning and Relationship Satisfaction. J Sex Marital Ther. 2015;41(6):672-9. doi: 10.1080/0092623X.2014.966398), and on what we generally consider a common way of thinking. We must consider that our population has been evaluated during the first lockdown, where due to the necessity to prevent the COVID infection, people were invited to stay at home. In this situation, it is reasonable to suppose that “forced” cohabitation, and shared activities may have contributed to a negative sexual well-being, rather than to improve it. We inserted this specification in the revised version of the manuscript (please, see discussion”).

 

Some data are reported with two decimals, some others with one decimal (which I think is the best choice).

We would thank the Reviewer for this suggestion. The manuscript has been amended.

 

Was a priori power calculation conduted? How or why not?

We would thank the Reviewer for this comment. Power calculation was conducted on the general sample recruited for the first study on the lockdown, from which data about elderly people have been extrapolated. This information has been added to the revised manuscript (please, see Methods).  

 

 

A comparison between two groups is meaningless if one group is five times as large as the other (males:females in this study).

We completely agree with the Reviewer’s opinion. Unfortunately, the percentage of elderly women declaring to have been sexually active during the first lockdown was very low. For this reason, as specified in the results, we decided to make the comparison between genders for only one variable, that is the perceived orgasmic intensity.

 

Author Response File: Author Response.doc

Reviewer 3 Report

Thank you for this interesting, cogent paper.  Such work on the sexuality of older people is clearly needed.

INTRO: English usage interferes with clarity.  E.g., page 2, rewrite sentence as "The link between psycho-emotional and the relational wellbeing and the sexual life is well known, and The sexual function at the old age" should be rewritten as "sexual function in old age."  Please have a native English speaker delete or replace problematic words.  

Methods: please give teh recall period for each of the measures.  In particular, does the orgasmometer have a recall period comparable to the other scales?

Results: in Table 2, give the best and worst possible scores.

Figure 1 is an excellent aid for understanding the correlations, but tell in text or footnotes what the boundaries are for the colored areas surrounding the lines (SD? SE? SEM? 25-75? The reader should be told.)

Author Response

Reviewer 3

Thank you for this interesting, cogent paper.  Such work on the sexuality of older people is clearly needed.

We would thank the Reviewer for her/his appreciation.

INTRO: English usage interferes with clarity.  E.g., page 2, rewrite sentence as "The link between psycho-emotional and the relational wellbeing and the sexual life is well known, and “The sexual function at the old age" should be rewritten as "sexual function in old age."  Please have a native English speaker delete or replace problematic words.  

Thank you very much for your suggestion. The manuscript has been now completely revised by a native mother-tongue English speaker.

Methods: please give teh recall period for each of the measures.  In particular, does the orgasmometer have a recall period comparable to the other scales?

Thank you very much for this specification. The recall period of each questionnaire has been specified in the methods of the revised manuscript. For what concerns the Orgasmometer, it has the same recall period of the FSFI, but not of SHIM, who refers to the last six months. Several critics have been made to the recall period of questionnaires evaluating sexual functioning (see for example Forbes et al. Critical flaws in the Female Sexual Function Index and the international index of Erectile Function. J Sex Res. 2014;51(5):485-91; Rosen et al. Commentary on "Critical flaws in the FSFI and IIEF". J Sex Res. 2014;51(5):492-7; Forbes. Response to Rosen et al. (2014) "Commentary on 'Critical flaws in the FSFI and IIEF'". J Sex Res. 2014;51(5):498-502), who range from four weeks to six months. However, for what concerns the Orgasmometer, we place trust in the fact that brief recall period may guarantee a better subjective remembering of the sexual pleasure. In addition, we must also consider that subjects’ enrolment and evaluation was made during the first Italian lockdown, that is between March and May 2020. Hence, we believe that in this way the possible limit related to different recall periods of specific tests has been passed.  

 

Results: in Table 2, give the best and worst possible scores.

We would thank the Reviewer for this comment. The table 2 has been amended.

 

Figure 1 is an excellent aid for understanding the correlations, but tell in text or footnotes what the boundaries are for the colored areas surrounding the lines (SD? SE? SEM? 25-75? The reader should be told.)

We would thank the Reviewer for this comment. The Figure 1 has been amended.

Author Response File: Author Response.doc

Round 2

Reviewer 2 Report

The authors did their best effort to improve their manuscript. They improved the quality of the English used, but it is not possible to evaluate the methodology if it is not not explained in the manuscript and if the reference to a previously published paper is not provided in full (I can understand the anonimization issues, but...).

All in all, most of my previous concerns are still standing (considering also that they tried to convince me that a mistake was right in statistical analysis... and provided a contradictory explanations regarding the use of online versions of pen-and-paper questionnaires).

Therefore, I cannot (and will not) change my opinion.

Author Response

Reviewer 2

The authors did their best effort to improve their manuscript. They improved the quality of the English used, but it is not possible to evaluate the methodology if it is not not explained in the manuscript and if the reference to a previously published paper is not provided in full (I can understand the anonimization issues, but...).

We would thank the Reviewer for recognizing our efforts. We tried to follow all the Reviewer’s suggestions, to improve the quality of our manuscript. We also agree with the necessity to describe the adopted methodology, to make more comprehensible the global study. Hence, in the methods of the revised manuscript we inserted a broader description of the methodology.

 

All in all, most of my previous concerns are still standing (considering also that they tried to convince me that a mistake was right in statistical analysis... and provided a contradictory explanations regarding the use of online versions of pen-and-paper questionnaires).

To clarify the Reviewer’s concerns, we respectfully would show, based on literature evidence, that the use of online version of pen-and-paper questionnaires is widely adopted, for several reasons. Here attached is a brief list of yet published articles in which the authors have adopted an online version of FSFI, IIEF, SHIM, DAS, PHQ and GAD. In addition, we have also specified in the Appendix 1 the rationale of this choice. In fact, due to the social isolation we couldn’t evaluate subjects with a vis-à-vis manner. We hope that the Reviewer can understand our reasons and accept, or respect, the web-based methodology, which represents likewise a valid strategy for the study of different populations.

1. Mykoniatis I, Grammatikopoulou MG, Bouras E, et al. Sexual Dysfunction Among Young Men: Overview of Dietary Components Associated With Erectile Dysfunction. J Sex Med. 2018;15(2):176-182. doi:10.1016/j.jsxm.2017.12.008
2. Greenberg DR, Khandwala YS, Bhambhvani HP, Simon PJ, Eisenberg ML. Male and Female Sexual Dysfunction in Pediatric Cancer Survivors [published online ahead of print, 2020 Jul 1]. J Sex Med. 2020;S1743-6095(20)30650-0. doi:10.1016/j.jsxm.2020.05.014
3. Sanders SA, Hill BJ, Janssen E, et al. General Erectile Functioning among Young, Heterosexual Men Who Do and Do Not Report Condom-Associated Erection Problems (CAEP). J Sex Med. 2015;12(9):1897-1904. doi:10.1111/jsm.12964
4. O'Sullivan LF, Brotto LA, Byers ES, Majerovich JA, Wuest JA. Prevalence and characteristics of sexual functioning among sexually experienced middle to late adolescents. J Sex Med. 2014;11(3):630-641. doi:10.1111/jsm.12419
5. Ferguson GG, Nelson CJ, Brandes SB, Shindel AW. The sexual lives of residents and fellows in graduate medical education programs: a single institution survey. J Sex Med. 2008;5(12):2756-2765. doi:10.1111/j.1743-6109.2008.01002.x
6. Zheng JB, Liang QF, Li JH, et al. Longitudinal Trends of AMS and IIEF-5 Scores in Randomly-Selected Community Men 40 to 80 Years Old: Preliminary Results. J Sex Med. 2019;16(10):1567-1573. doi:10.1016/j.jsxm.2019.07.017
7. Saotome TT, Yonezawa K, Suganuma N. Sexual Dysfunction and Satisfaction in Japanese Couples During Pregnancy and Postpartum. Sex Med. 2018;6(4):348-355. doi:10.1016/j.esxm.2018.08.003
8. Weiss P, Brody S. International Index of Erectile Function (IIEF) scores generated by men or female partners correlate equally well with own satisfaction (sexual, partnership, life, and mental health). J Sex Med. 2011;8(5):1404-1410. doi:10.1111/j.1743-6109.2011.02214.x
9. Breyer BN, Smith JF, Eisenberg ML, Ando KA, Rowen TS, Shindel AW. The impact of sexual orientation on sexuality and sexual practices in North American medical students. J Sex Med. 2010;7(7):2391-2400. doi:10.1111/j.1743-6109.2010.01794.x
10. Nazarpour S, Simbar M, Ramezani Tehrani F, Alavi Majd H. Effects of Sex Education and Kegel Exercises on the Sexual Function of Postmenopausal Women: A Randomized Clinical Trial. J Sex Med. 2017;14(7):959-967. doi:10.1016/j.jsxm.2017.05.006
11. Crisp C, Vaccaro C, Fellner A, Kleeman S, Pauls R. The influence of personality and coping on female sexual function: a population survey. J Sex Med. 2015;12(1):109-115. doi:10.1111/jsm.12735
12. Çömez S, Karayurt Ö. The effect of web-based training on life quality and spousal adjustment for women with breast cancer and their spouses. Eur J Oncol Nurs. 2020 Aug;47:101758. doi: 10.1016/j.ejon.2020.101758.
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14. Lasalvia A, Bodini L, Amaddeo F, Porru S, Carta A, Poli R, Bonetto C. The Sustained Psychological Impact of the COVID-19 Pandemic on Health Care Workers One Year after the Outbreak-A Repeated Cross-Sectional Survey in a Tertiary Hospital of North-East Italy. Int J Environ Res Public Health. 2021 Dec 19;18(24):13374. doi: 10.3390/ijerph182413374.
15. Rillera Marzo R, Villanueva Iii EQ, Chandra U, Htay MNN, Shrestha R, Shrestha S. Risk perception, mental health impacts and coping strategies during COVID-19 pandemic among Filipino healthcare workers. J Public Health Res. 2021 Dec 15. doi: 10.4081/jphr.2021.2604.
16. Schneider JN, Hiebel N, Kriegsmann-Rabe M, Schmuck J, Erim Y, Morawa E, Jerg-Bretzke L, Beschoner P, Albus C, Hannemann J, Weidner K, Steudte-Schmiedgen S, Radbruch L, Brunsch H, Geiser F. Moral Distress in Hospitals During the First Wave of the COVID-19 Pandemic: A Web-Based Survey Among 3,293 Healthcare Workers Within the German Network University Medicine. Front Psychol. 2021 Nov 18;12:775204. doi: 10.3389/fpsyg.2021.775204. eCollection 2021.
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Therefore, I cannot (and will not) change my opinion.

We hope that our new modifications of the manuscript can change the Reviewer’s opinion. We remain available for any other clarification.