Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis

Loraine Ledón-Llanes; Irazú Contreras-Yáñez; Guillermo Arturo Guaracha-Basáñez; Salvador Saúl Valverde-Hernández; Maximiliano Cuevas-Montoya; Ana Belén Ortiz-Haro; Virginia Pascual-Ramos

doi:10.1371/journal.pone.0305831

. 2024 Aug 26;19(8):e0305831. doi: 10.1371/journal.pone.0305831

Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis

Loraine Ledón-Llanes ^1,^#, Irazú Contreras-Yáñez ^2,^#, Guillermo Arturo Guaracha-Basáñez ^2,^#, Salvador Saúl Valverde-Hernández ^2,^#, Maximiliano Cuevas-Montoya ^2,^#, Ana Belén Ortiz-Haro ^2,^#, Virginia Pascual-Ramos ^2,^*,^#

Editor: Milad Khorasani³

PMCID: PMC11346937 PMID: 39186754

Abstract

Background

Rheumatoid arthritis (RA) is a chronic disease with worldwide representation that impacts every domain of a patient´s life, extending to sexual and reproductive domains. The study characterized sexual health (SH) and reproductive health (RH) in Mexican RA outpatients and identified factors associated with impaired sexual function (ISF).

Methods

From September 1, 2020—January 31, 2022, consecutive RA participants had semi-structured interviews focusing on their SH and RH biographies, and self-administered questionnaires were applied to assess patient-reported outcomes, including fatigue with the Functional Assessment of Chronic Illness Therapy-Fatigue scale (FACIT-F). ISF was defined based on published cut-offs of the International Index of Erectile Function (IIEF) in males and the Female Sexual Function Index (FSFI) in females (≥1 sexual intercourse in the last four weeks was required for index scoring). Multivariable logistic regression analysis was used to identify the factors associated with ISF.

Results

There were 268 participants, and 246 (91.8%) were females. Participants had 13 years of disease duration. Among females, 151 (61.4%) had FSFI applied, and the satisfaction domain was impaired in 111 (73.5%). Among males (N = 22), 17 (77.3%) had IIEF applied, and erectile dysfunction was present in 5 (29.4%). Almost half of the participants denied using a family planning method, were in their 50s, and receiving teratogenic drugs; 89.7% of the participants had children.

ISF was detected in 94 (62.3%) females and 3 (17.6%) males. Male sex (aOR: 0.07, 95%CI: 0.01–0.36, p = 0.001), FACIT-F score (aOR: 0.96, 95%CI: 0.92–1.00, p = 0.03), and cohabitation with the couple (aOR: 0.32, 95%CI: 0.11–0.96, p = 0.04) were associated with ISF.

Conclusions

We observed a disproportionate burden of ISF among women with RA compared to male participants. Male sex, lesser fatigue, and cohabitation with the couple were protective against ISF. Regardless of the prevalent use of teratogenic medications, contraceptive use was suboptimal among the participants.

Introduction

Rheumatoid arthritis (RA) is one of the most common immune-mediated diseases, with a remarkably consistent prevalence worldwide, at about 0.5% to 1% [1]. The disease has a female preponderance. In Caucasians, it is two to three times as common among females as males and can occur at any age, but the incidence peaks in the third through the fifth decades of life [1]. RA is characterized by pain, systemic inflammation, progressive articular damage, and extra-articular manifestations. If uncontrolled, it might cause disability and impact every domain of a patient´s life [2], extending to sexual and reproductive domains [3].

Sexual and reproductive health is a complex construct, integrated by two dimensions, sexual health (SH) and reproductive health (RH), that are recommended to be addressed separately [4]. Moreover, the World Health Organization (WHO) recognized SH as an umbrella term that includes RH [5]. SH and RH are greatly influenced by the social, cultural, educational, and economic conditions of the community where people are born and live [4]. Systematic literature reviews have consistently revealed an impact of RA on SH and RH in both women and men [6–9]. Meanwhile, research on attribution to the dysfunction of either dimension among RA patients has shown conflicting results. Impaired SH has been related to RA symptoms and reduced patient function [10–19], the long and chronic course of the disease [20,21], comorbid conditions with emphasis on mental health comorbidities [19,22–25], the medications used [26,27], and hormone imbalance [28,29]. RH in RA patients has focused on reduced fertility [30–35], which has been related to the disease process itself [30,33–35], the therapy [29], gonadal dysfunction [36], physicians’ advice to patients [30,31], and patients own decisions [30,31]. A higher frequency of adverse outcomes has also been described in pregnancies that occurred after RA onset, compared to the pre-RA obstetric path [37].

RA presents particular characteristics in the Latin American region, which are not limited to a younger age at presentation and extreme female preponderance compared to Caucasian populations [38]. Nationality and ethnicity also influence patient perceptions and views regarding the RA priority domains, concerns, and interests [39,40], the ways SH and RH are conceptualized [41], and the preferred patient-doctor relationship [42]. These characteristics shape patients’ experiences and how they are communicated to physicians.

Finally, the Corona Virus Disease 2019 (COVID-19) pandemic has threatened people´s physical and mental health worldwide, including patients with rheumatic diseases [43]. Additionally, the pandemic has led to issues in public health ethics. The need to serve patients with COVID-19 has translated into rationing the care of patients with chronic conditions, which has aggravated existing disparities [44]. World regions where public life was characterized by fragile health systems and long-standing and pervasive inequity, such as Latin America, have faced a humanitarian crisis [45]. Besides, the lockdown produced deep and abrupt changes in personal, family, and social life, increasing distress and intra-family violence, particularly in women and in Mexico compared to other countries [46]. Because of the close relationship between psychological components and sexual function, several studies have shown decreased sexual activity during the social restriction period due to the COVID-19 pandemic [47].

Considering the above arguments, the study aimed to comprehensively characterize SH and RH in Mexican RA outpatients and identify relevant factors associated with impaired sexual function (ISF). We were particularly interested in determining disease activity and COVID-19 pandemic-related characteristics.

Materials and methods

Setting and participants

The INCMyN-SZ is a quaternary care national referral center for rheumatic diseases in Mexico City. Participants were identified from the Department of Immunology and Rheumatology outpatient clinic. Consecutive RA patients waiting for a scheduled consultation were invited to participate. RA diagnosis was based on the treating rheumatologist’s criteria (all were board-certified). Exclusion criteria were RA patients with overlapping rheumatologic syndrome (except Secondary Sjögren Syndrome) and patients with uncontrolled comorbidity requiring treatment intensification or palliative care.

Study design, study assessments, and data collection

This cross-sectional study was conducted between September 1, 2020, and January 31, 2022. STROBE´s guidelines were followed (Please refer to the SI “STROBE checklist for cross-sectional studies,” S1 Appendix).

All the participants had a 30–60 minutes-duration semi-structured interview using an interview guide to assess the following aspects: socio-demographics (including partner-related information), relevant information related to current and past psychiatric and medical conditions, current treatments, legal/illegal substance use (including psychopharmaceuticals) and an extensive SH and RH biographies which included the exploration of the participants’ perception about the effects of the COVID-19 pandemic on their lives.

After that, self-administered Spanish versions of the following questionnaires (paper format) were provided to the participants: the Hospital Anxiety and Depression Scale (HADS) [48], the Routine Assessment of Patient Index Data 3 (RAPID-3) to assess disease activity/severity [49], the Euro Qol-5 dimensions (EQ-5D) to evaluate health related-quality of-Life [50], the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) [51], the International Index of Erectile Function (IIEF) in male participants and the Female Sexual Function Index (FSFI) in female participants [52]. Also, considering the study’s inclusion period, a self-administered COVID-19 survey to address healthcare interruption, individuals´ perception of the pandemic seriousness in the country, participants’ risk perception of SARS-CoV-2 infection, participants follow-up of physical distancing recommendation, the family economic and relational impact attributed to COVID-19 pandemic and ten negative emotions attributed to the COVID-19 pandemic was filled out by the participants [53] (Please refer to the S2 “COVID-19 Survey”, S2 Appendix). Interviews and questionnaires administration were scheduled in a private room.

Finally, participants had their charts reviewed by a data abstractor who used standardized formats to confirm sociodemographic information, RA-related characteristics, treatment, and Charlson score [54]. Only the person responsible for the data collection had access to information that could identify individual participants; none of this information was transferred to the database, so no research team member had access to it after this process.

Measures

ISF in male participants

It was diagnosed based on the IIEF score. The IIEF is a multi-dimensional self-report instrument for evaluating male sexual function over the previous four weeks, which focuses on erectile function/dysfunction (ED). The IIEF includes 15 items distributed into five relevant domains of male sexual function: erectile function (five items), orgasmic function (two items), sexual desire (two items), intercourse satisfaction (three items), and overall satisfaction (two items). For each sexual domain, a score is calculated, and the six domain scores can be added to obtain a score from 5–75, with higher scores indicating better sexual function. The total “erectile function” score ranges from 6–30 with a cut-off for ED<26. Additional cut-off values were used for the other sexual domains based on a qualitative analysis in which the diminished and the presence of difficulties were interpreted as impairing indicators [55]. Therefore, each domain under 60% score (<6 in orgasmic function, sexual desire, overall satisfaction, each, and <9 in intercourse satisfaction) was considered impaired. The cut-off value for the total sexual function score was determined by adding the cut-off values of each sexual function domain. Hence, a total IIEF score of <53 was considered ISF. At least one sexual intercourse in the last four weeks was required to provide an IIEF score.

ISF in female participants

It was diagnosed based on the FSFI score. The FSFI is a 19-item self-report inventory designed to assess critical domains of female sexual function over the previous four weeks. Items are distributed into six domains: desire (two items), arousal (four items), lubrication (four items), orgasm, satisfaction, and pain (three items each). The FSFI total score is the sum of the six domain scores and ranges from 2 to 36. Higher scores indicate better functioning. In clinical practice, an FSFI cut-off score of <26.55 has been widely used to define ISF, while a score <3.9 is considered an impairment for each sexual function domain [21,56]. At least one sexual intercourse in the last four weeks was mandatory to score the IIEF.

RA-disease activity categories

They were defined based on RAPID-3 scores [49]. The RAPID-3 includes three measures: physical function, pain, and a patient global estimate evaluation. It has a raw score of 0–30 and an adjusted score of 0–10, with higher scores translating into higher disease activity/severity. Four proposed categories are defined based on 0–30 scale cut-offs: >12 as high disease activity, 6.1–12.0 as moderate disease activity, 6.0–3.1 as low disease activity, and ≤three near-remission.

Sexual discomforts

Sexual expressions that, although they do not constitute sexual dysfunction according to the clinical criteria (APA 2013), have negative effects on sexual well-being from the patient´s subjective assessment [57].

Sample size calculation

Previous studies have found disease activity parameters (pain, fatigue, erythrocyte sedimentation rate, and disease activity score) and impaired function as significant determinants for ISF [10,12,14,17,22]. We selected the RAPID-3, which accounts for disease activity and severity. We arbitrarily hypothesized an effect size of odds ratio (OR) 2.5 in a no-normal distribution. We estimated the sample size using a one-tailed test, 5% significance level, and 80% power. We obtained (at least) 151 patients. The final sample size and the participants´ distribution gave us 80% power for a one-tailed test to detect an effect size of 0.29.

Statistical analyses

We performed a descriptive statistical analysis, presenting frequencies for categorical variables and median (interquartile range, [IQR]) for numerical variables.

Characteristics of participants with ISF were compared to those of their counterparts using appropriate tests. The Mann-Whitney U test was used to compare continuous variables between two groups when they did not show a normal distribution (Kolmogorov-Smirnov). Fisher’s exact test or X² test was used to compare proportions.

Multivariable logistic regression analysis was performed to identify factors associated with ISF. We initially conceived a global model where variables’ inclusion was based on their statistical significance in the univariable analysis (p≤0.10) and/or their clinical relevance; in particular, RAPID-3 was forced into the models tested. A test-based backward selection was used to define the final model. Correlations between variables were examined to avoid overfitting the models, and when relevant (rho>0.70), only one variable was selected. The Nagelkerke pseudo-R² test is reported as a measure of model fit goodness. Results are expressed as OR and adjusted OR (aOR) (exponentiated regression coefficients, exp[β] and their 95% confidence interval). The following variables were considered for aOR: age, sex, being in a relationship, time in a relationship, cohabitation with the couple, FACIT-F score, the self-care and usual activities domains of the EQ-5D, past sexual discomforts, RAPID-3 score, and infertility diagnosis. A value of p≤0.05 was considered statistically significant.

Missing data varied from 0 to 20% of the individual items, and no imputation was performed. Reasons for missing data included participants skipping answers and patients selecting the “I do not want to answer” option.

All statistical analyses were performed using Statistical Package for the Social Sciences version 21.0 (SPSS Chicago IL).

Ethics

The Research Ethics Committee of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMyN-SZ) approved the study (reference number: IRE-3388-20-21-1). All the patients included provided written informed consent.

Results

Overall population characteristics

During the study period, we included 268 RA participants. Table 1 summarizes participants’ characteristics, including socio-demographics, RA-related and mental-health-related features, and COVID-19-related information. The distribution among female and male participants is also presented.

Table 1. Socio-demographics, RA-related, mental-health-related, and COVID-19-related characteristics in the participants enrolled in the study, female and male participants.

Variable category (n1/n2/n3)	All participants	Female participants	Male participants
Socio-demographic characteristics
Females (268/246/22)	246 (91.8)	246 (100)	NA
Years of age* (268/246/22)	47 (38–53)	47 (38–53)	42 (34.8–52.3)
Years of Scholarship* (268/246/22)	12 (9–16)	12 (9–16)	12 (9–16)
Occupation Formal job (268/246/22) Non-formal job (268/246/22) Household work (268/246/22)	98 (36.1) 44 (16.4) 119 (44.4)	91 (37) 32 (13) 119 (48.4)	7 (31.8) 12 (54.5) 0
Religious beliefs Catholics (268/246/22) Non-religious (268/246/22)	198 (73.9) 38 (14.2)	180 (73.2) 34 (13.8)	18 (81.8) 4 (18.2)
Relationship Being in a relationship (268/246/22) Years in a relationship¹* (268/246/22) Stable bond¹ (268/246/22) Cohabitation with the couple¹ (268/246/22)	191 (71.3) 18 (6–30) 170 (89) 148 (77.5)	172 (69.9) 15.8 (6–30) 153 (88.9) 134 (77.9)	19 (86.4) 18 (6–30) 17 (89.5) 14 (73.7)
RA-related characteristics
Years of disease duration* (268/246/22)	13 (8–18)	13 (8–18)	10 (4.5–15.5)
Charlson score* (268/246/22)	1 (1–1)	1 (1–1)	1 (1–1)
Comorbidities (268/246/22)	143 (53.4)	132 (53.7)	11 (50)
Use of prednisone (268/246/22)	95 (35.4)	87 (35.4)	8 (36.4)
N° DMARDs/patient* (268/246/22)	1 (1–2)	1 (1–2)	1 (1–2)
RAPID 3 score (0–30)* (268/246/22)	7.7 (2.3–14.3)	7.9 (2.3–14.3)	3.8 (0.8–10.8)
Low disease activity and near remission (RAPID3 score ≤6) (268/246/22)	115 (42.9)	101 (41.1)	14 (63.6)
FACIT-F score* (0–52) (268/246/22)	11 (5–20)	11 (5–20)	10.5 (3.5–17)
EQ-5D (No problems) Mobility (245/226/19) Self-care (245/226/19) Usual activities (245/226/19) Pain and discomfort (245/226/19) Anxiety and depression (245/226/19)	143 (58.4) 181 (73.9) 139 (56.7) 74 (30.2) 138 (56.3)	131 (58) 166 (73.5) 128 (56.6) 67 (29.6) 127 (56.2)	12 (63.2) 15 (78.9) 11 (57.9) 7 (36.8) 11 (57.9)
Mental health-related characteristics
Mental health comorbidity (256/238/18)	32 (12.5)	31 (13)	1 (5.6)
Legal/illegal substances use/abuse (268/246/22)	24 (9)	17 (6.9)	7 (31.8)
Psychotropic drugs (230/214/16)	16 (7)	16 (7.5)	0
HADS score* Depression score (0–21) (268/246/22) Anxiety score (0–21) (268/246/22)	3 (1–6) 5 (3–8)	3 (1–6) 5 (3–8)	2.5 (1–4.3) 5 (3–8)
Abnormal HADS score (>11) (268/246/22)	99 (36.9)	93 (37.8)	6 (27.3)
COVID-19-related characteristics
Healthcare interruption (257/237/20)	174 (67.7)	158 (66.7)	16 (80)
RA-related treatment changes because of the COVID-19 pandemic (252/232/20)	132 (52.4)	125 (53.9)	7 (35)
Patients´ follow-up of recommendations to contain virus spread (Always/Most of the time) (253/234/19)	207 (81.8)	192 (82.1)	15 (78.9)
Patient’s perception of the pandemic seriousness in Mexico (Very high/ High) (252/234/18)	232 (92.1)	215 (91.9)	17 (94.4)
Patient´s risk perception of Sars-Cov-2 infection (High/Very High) (216/202/14)	92 (42.6)	86 (42.6)	6 (42.9)
Feeling anxious (251/233/18)	79 (31.5)	74 (31.8)	5 (27.8)
Feeling worried (253/235/18)	115 (45.5)	108 (46)	7 (38.9)
Feeling fearful (250/232/18)	85 (34)	79 (34.1)	6 (33.3)
Feeling alertness (257/235/18)	144 (56)	135 (57.4)	9 (50)
Feeling depressed (251/233/18)	43 (17.1)	42 (18)	1 (5.6)
Feeling confused (250/233/17)	49 (19.6)	46 (19.7)	3 (17.6)
Feeling alarmed (252/234/18)	81 (32.1)	77 (32.9)	4 (22.2)
Feeling isolated (252/234/18)	102 (40.5)	97 (41.5)	5 (27.8)
Feeling discriminated against (250/232/4)	13 (5.2)	13 (5.6)	0
Feeling bored (246/228/18)	58 (23.6)	54 (23.7)	4 (22.2)
Negative family economic impact attributed to the COVID-19 pandemic (232/214/18)	184 (79.3)	170 (79.4)	14 (77.8)
COVID-19’s negative impact on family members’ relationships (233/215/18)	123 (52.8)	115 (53.5)	8 (44.4)
Intercourse-related activity modifications during the COVID-19 pandemic (233/213/20)	81 (34.7)	74 (34.7)	7 (35)

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Data are presented as n (%) unless *represents the median (IQR). n1 = data available in all the participants; n2 = data available in female participants; n3 = data available in male participants. ¹Among those with the condition. DMARDs = Disease modifying anti-rheumatic drugs. RAPID-3 = Routine Assessment of Patient Index Data 3. FACIT-F = Functional Assessment of Chronic Illness Therapy–Fatigue. EQ-5D = Euro Qol 5 dimensions. HADS = Hospital Anxiety and Depression Scale (HADS). NA = Not applicable.

SH in the entire population

There were 11 out of 253 (4.3%) participants who reported they had past sexual discomforts (15 data unavailable [U]), while 52 out of 179 (29.1%) reported current sexual discomforts (89 U), among whom only 5 (2.8%) received related interventions.

The majority of the participants (245 [91.4%]) had the sexual desire domain scored, and 168 (62.7%) referred to at least one sexual intercourse in the previous four weeks, which was required to score indices related to sexual function.

Among female participants (N = 246), 151 (61.4%) have the FSFI scored, and the median global score was under the cut-off, 25 (22–28). Fig 1 summarizes the distribution of impaired FSFI domains. ISF was present in 94 (62.3%) female participants.

Among male participants (N = 22), 17 (77.3%) scored the IIEF, and the median global score was 64 (57–70). Fig 1 presents the distribution of impaired IIEF domains. ISF was present in only 3 participants (17.6%).

RH in the entire population

In the whole population, 204 (79.7%) participants (12 data U) mentioned past use of a family planning method, while only 128 out of 258 (49.6%) mentioned current usage. Among them, the condom was the most frequently used by 44 (34.3%) participants, 43 (33.5%) mentioned tubal ligation, and 16 (12.5%) intrauterine implants. Interestingly, participants who denied using a family planning method had a median (IQR) of 49.5 (41–55) years of age (vs. 43 [36–49] years of age in the participants with current usage of a family planning method), were indicated DMARDs (124 [95.4%]) and most frequently methotrexate (91 [73.4%]), while only 9 (7%) participants had infertility diagnosis.

Also, 182 females out of 246 (74%) reported pregnancies, with a median (IQR) of 2 (2–3) pregnancies. Overall, 183 participants out of 204 (89.7%) had children with 2 (1–3) children/participant.

Finally, past and current sexually transmitted infections (STI) were reported by 41 in 251 participants (16.3%) and 2 in 223 (2.7%), respectively, and papillomavirus infections were the most prevalent.

Comparison of participants with and without ISF

Overall, 168 participants met the criteria to score the indices. Their characteristics were compared to those of the 100 participants to whom the index did not apply. Overall, participants from both groups were similar, but being in a relationship in which participants were more frequently referred from the former group (147/168 [87.5%] vs. 44/100 [44%], p≤0.001), in addition to having a stable bond (135/146 [92.5%] vs. 35/44 [79.5%], p≤0.001), having current sexual discomforts (41/115 [35.7%] vs. 11/64 [17.2%], p = 0.01) and a High/Very high-risk perception of SARS-Cov-2 infection (65/136 [47.8%] vs. 27/80 [33.8%], p = 0.05).

Overall, 97 (57.7%) participants had ISF, and their sociodemographic, RA-related, mental health-related, and COVID-19 characteristics were compared to their counterparts (N = 71 [42.3%]) and are summarized in Table 2 (the p-value is derived from the comparison of the characteristics between participants with ISF and their counterparts, using appropriate tests).

Table 2. Comparison of sociodemographic, RA-related, mental health-related, and COVID-19-related characteristics between participants with ISF and their counterparts.

Variable category (n1/n2)	Participants with ISF	Participants without ISF	p
Socio-demographic characteristics
Females (97/71)	94 (96.9)	57 (80.3)	0.001
Years of age* (97/71)	47 (36–52.5)	46 (38–53)	0.67
Years of Scholarship* (97/71)	12 (9–16)	12 (9–16)	0.15
Formal/Non-formal job (97/71)	49 (50.5)	35 (49.3)	1
Religious beliefs (97/71)	79 (81.4)	63 (88.7)	0.28
Relationship Being in a relationship (97/71) Years in a relationship¹* (97/71) Stable bond¹ (97/71) Cohabitation with the couple¹ (97/71)	81 (83.5) 14 (3–28) 75 (92.6) 57 (70.4)	66 (93) 20 (9–39) 60 (84.5) 56 (84.8)	0.10 0.10 1 0.02
RA-related characteristics
Years of disease duration* (97/71)	12 (8–16)	14 (18–20)	0.32
Charlson score* (97/71)	1 (1–1)	1 (1–1)	0.33
Comorbidities (97/71)	50 (51.5)	34 (47.9)	0.26
Use of prednisone (97/71)	39 (40.2)	22 (31)	0.26
N° DMARDs/patient* (97/71)	1 (1–2)	1 (1–2)	0.35
RAPID 3 score (0–30)* (97/71)	6.5 (1.7–14.3)	8 (3.6–15)	0.39
Low disease activity and near remission (RAPID3 score ≤6) (97/71)	47 (48.5)	29 (40.8)	0.35
FACIT-F score* (0–52) (97/71)	10 (4.5–18)	13 (8–20)	0.05
EQ-5D (No problems) Mobility (95/66) Self-care (95/66) Usual activities (95/66) Pain and discomfort (95/66) Anxiety and depression (95/66)	61(64.2) 78 (82.1) 64 (67.4) 34 (35.8) 58 (61.1)	38 (57.6) 44 (66.7) 34 (51.5) 156 (22.7) 37 (56.1)	0.42 0.04 0.04 0.19 0.77
Mental health-related characteristics
Mental health comorbidity (96/68)	15 (15.6)	9 (13.2)	0.82
Legal/illegal substances use/abuse (97/71)	8 (8.2)	8 (11.3)	0.47
Psychotropic drugs (84/64)	8 (9.5)	3 (4.7)	0.27
HADS score* Depression score (0–21) (97/71) Anxiety score (0–21) (97/71)	3(1–5) 6 (3–8)	4 (1.8–6.3) 5 (3–8)	0.12 0.84
Abnormal HADS score (>11) (97/71)	34 (35.1)	28 (39.4)	0.63
COVID-19-related characteristics
Health care interruption (93/69)	58 (62.4)	47 (68.1)	0.55
RA-related treatment changes because of the COVID-19 pandemic (89/68)	43 (48.3)	38 (55.9)	0.42
Patients´ follow-up of recommendations to contain virus spread (Always/Most of the time) (90/68)	75 (81.5)	58 (85.3)	0.67
Patient’s perception of the pandemic seriousness in Mexico (Very high/ High) (77/59)	84 (93.3)	59 (86.8)	0.18
Patient´s risk perception of Sars-Cov-2 infection (High/Very High) (77/59)	36 (46.8)	29 (49.2)	0.87
Feeling anxious (92/65)	27 (29.3)	23 (35.4)	0.49
Feeling worried (92/67)	41 (44.6)	34 (50.7)	0.52
Feeling fearful (92/65)	33 (35.9)	22 (33.8)	0.87
Feeling alertness (92/67)	59 (64.1)	40 (59.7)	0.74
Feeling depressed (92/66)	17 (18.5)	10 (15.2)	0.67
Feeling confused (92/66)	17 (18.5)	13 (19.7)	0.84
Feeling alarmed (92/67)	29 (31.5)	19 (28.4)	0.73
Feeling isolated (92/66)	43 (46.7)	25 (37.9)	0.33
Feeling discriminated against (92/66)	6 (6.5)	3 (4.5)	0.74
Feeling bored (92/64)	24 (26.1)	17 (26.6)	1
Negative family economic impact attributed to the COVID-19 pandemic (88/61)	68 (77.3)	47 (77)	1
COVID-19’s negative impact on family members’ relationships (89/61)	40 (44.9)	25 (41)	0.29
Intercourse-related activity modifications during the COVID-19 pandemic (68/57)	31 (45.6)	23 (40.4)	0.48

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Data are presented as n (%) unless *represents the median (IQR). n1 = data available in participants with ISF; n2 = data available in participants without ISF. ¹Among those with the condition. DMARDs = Disease modifying anti-rheumatic drugs. RAPID-3 = Routine Assessment of Patient Index Data 3. FACIT-F = Functional Assessment of Chronic Illness Therapy–Fatigue. EQ-5D = Euro Qol 5 dimensions. HADS = Hospital Anxiety and Depression Scale (HADS).

Participants from the former group also mentioned less frequent past sexual discomforts (30/91 [33%] vs. 34/67 [50.7%], p = 0.03), while current sexual discomforts (22/67 [33.8%] vs. 19/49 [38.8%], p = 0.56) and related treatments (2/27 [7.4%] vs. 0, p = 0.49) were similar. As expected, (median, IQR) SF-index scores differed between groups (22.7 [18.4–24.5] in females with ISF vs. 30 [27.8–31.5] in counterpart females and 44 [39–51] in males with ISF vs. 66 [62–71] in counterpart males, p≤0.001 for both). Also, in male and female subpopulations, there was a higher proportion of participants with impaired IIEF and FSFI-specific domains among those with ISF (Fig 2).

Fig 2 — Data presented as N° of patients (%). ISF = Impaired Sexual Function.

Finally, five RH characteristics were considered relevant to sexual function. They were compared between both groups: menstruation in the previous year (restricted to females), current use of a contraception method, perception of fertility hinders, infertility diagnosis, and a current reproductive project. Participants with ISF were similar to their counterparts, but the former participants had more frequent infertility diagnoses than their counterparts: 8 out of 71 participants (11.3%) vs. 3 out of 97 (3.1%), p = 0.05.

Factors associated with ISF

Different models were tested and yielded similar results. Table 3 presents OR and aOR, 95% CI, and p values for all the variables included in the model. Fig 3 summarizes the variables that ended up being significantly associated with ISF: the FACIT-F score (protective), cohabitation with the couple (protective), and male sex (protective) (R² = 0.22).

Table 3. OR and aOR (95% CI and p-value) for all the variables included in the multivariable logistic regression analysis.

	OR, (95% CI), p	aOR, (95% CI), p
Age (years)	1.00, (0.97–1.02), 0.74	1.01, (0.92–1.12), 0.86
Male sex	0.13, (0.04–0.47), 0.002	0.20, (0.02–1.70), 0.14
Being in a relationship	0.38, (0.14–1.10), 0.08	0.35 (0.21–1.51), 0.11
Time in a relationship (years)	0.98, (0.96–1.01), 0.17	1.01, (0.93–1.08), 0.93
Cohabitation with the couple	0.04, (0.13–0.86), 0.02	0.51, (0.07–3.92), 0.51
FACIT-F score	0.98, (0.95–1.01), 0.10	0.91, (0.83–1.01), 0.08
Self-care domain of EQ-5	0.44, (0.21–0.91), 0.03	0.34, (0.06–1.95), 0.23
Usual activities domain of EQ-5	0.52, (0.27–0.98), 0.044	0.85, (0.14–4.86), 0.86
Past sexual discomforts	0,48, (0.25–0.91), 0.03	0.79, (0.23–2.72), 0.71
RAPID-3 score	0.99 (0.95–1.03), 0.52	1.14, (0.98–1.34), 0.10
Infertility diagnosis	0.43, (0.14–1.37), 0.15	0.28, (0.04–1.79), 0.18

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Discussion

In the current study, we first observed that the vast majority of female participants had ISF, up to 61.4%, while it was present in only 17.6% of male participants. In females, sexual function domains more frequently affected were satisfaction, desire, and arousal, while erectile function and intercourse satisfaction were more frequently impaired in males. Second, almost half of the participants of the study affirmed using a family planning method, while non-users were in their 50s and primarily receiving teratogenic drugs. Also, most of the participants had more than one child. STIs, primarily papillomavirus, were present in a minority of the participants. Third, we identified three factors that were protective against ISF, namely, male sex, FACIT-F score, and cohabitation with the couple.

Our prevalence of ISF among women with RA and the pattern of the domains more frequently affected is consistent with that reported in reviews and original articles [6,14,58–60]. In a study of 100 sexually active Mexican women with RA and 100 healthy controls, the authors found that up to 49% of the patients experienced ISF based on the FSFI score. Similar to our findings, 50% of the patient participants experienced arousal impairment, although the overall pattern of sexual dysfunction differed from that observed in our patients. These differences could be due to the fact that our patients were older, more frequently active workers, and had their disease under control compared to those described by Rojo-Contreras et al. [60]. These differential characteristics have been shown to impact sexual function. However, our results on male participants differed from those published in a systematic review, where ISF was observed in 33% to 62% of the participants, and a more significant impact on sexual function in males was highlighted [7]. Physical function and disease activity play a more conclusive role among men than women in sexual function [13,61]. Our male participants scored low on the physical function score of the RAPID3 (median 0.5 [0–3.1]), which translates into a better function and might impede visualizing the intrusiveness of the disease itself in our males´ sexual function. Also, male participants showed few impaired domains, which might have contributed to a better global sexual function score [62].

Previous reports have confirmed a high prevalence of lack of contraception among childbearing ability patients with rheumatic diseases [63,64], which has been explained by rheumatologists rarely addressing pregnancy issues [65–67] and the multiple known barriers to contraceptive access [68]. In addition, an increased rate of infertility is currently assumed in RA females and males. We were intrigued by the family size of our participants, which does not substantially differ from that observed in Mexicans [69] and might be related to age at disease diagnosis, around their forties, when decisions to have children have already been made. The participants in our study reported a 16.3% prevalence of past and current sexually transmitted infections (STIs), mostly papillomavirus infections. Previous studies have shown varying prevalence rates among Mexican women with RA [60,70], which could be attributed to differences in the criteria used to diagnose STIs (self-reported vs. physician-established) and the widespread vaccination efforts in recent decades, especially in urban areas [71].

Sex, a biological variable, contributes to several pathogenic and epidemiologic aspects of RA, generating significant differences between affected males and females, which might explain why the male sex was protective against ISF. Overall, RA seems more severe in women, in whom more frequent comorbidities that impact sexual function, such as fibromyalgia and depression, are frequently observed [72]. Moreover, the use of common drugs for treating RA may be conditioned/halted during childbearing age, pregnancy, and lactation by the potential teratogenicity and the effects on female fertility [72]. Meanwhile, gender, which refers to the non-physiological components of sex regarded as appropriate to males and females from a sociocultural point of view, is intimately connected to behaviors and actions that impact health and access to healthcare and might be considered a determinant of SH and RH, particularly for women [73]. Our results related to the FACIT-F score agree with previous reports and literature reviews that associated fatigue with ISF in males [6,7,11,19] and females [6,11,12,57]. Fatigue impacts sexual function by decreasing sexual drive and interfering with sexual intercourse [74], while it might also express mental health comorbidity [75]. Finally, the fact that cohabitation with the couple was protective for ISF indicates that it might offer compensatory factors, such as more frequent sexual opportunities, that offset the adverse effects of the rheumatic disease [61]. The partners also have a critical role in influencing well-being, especially for those coping with chronic illness. Most RA patients perceived significant support from their partners [76], and spouses’ responses are crucial in promoting adaptation in individuals with chronic pain [77]. These are expressions of the dyadic coping with RA consequences on patients’ biography that might positively affect patients’ intimacy and sexuality. We could not replicate previous observations in female Mexican patients that suggested an association between menopause and sexual dysfunction, with methotrexate use being protective [60]. Our study included male participants (affecting disease activity), variations in socio-demographics (age, cohabitation, working subpopulation), clinical characteristics (disease duration, disease activity level, and prevalence of STIs), and treatment (prednisone use, number of DMARDs), which may explain the conflicting results. Moreover, the results of regression analysis are influenced by the variables included in the models, which differed between both studies.

It is intriguing that factors related to the COVID-19 environment did not impact patients’ sexual function. A recent systematic review and metanalysis of 134 cohorts, aimed at synthesizing mental health outcomes before and during the COVID-19 pandemic, found that at a population level, rather than a mental health crisis, there has been a high level of resilience during COVID-19 and changes in general mental health, anxiety symptoms, and depression symptoms have been minimal to small [78].

The study has some limitations that need to be addressed. Some of these limitations affect the external validity of our findings. Firstly, the participants were recruited from a single academic center in an urban area, which may not represent a diverse population of RA patients. Secondly, the participants primarily had long-standing diseases, and there was an underrepresentation of men. Thirdly, the assessment of sexual function required at least one sexual intercourse in the last four weeks, which may not be applicable to all participants. Additionally, the methods used to assess SF may be biased towards cisgender heterosexual patients. There are also limitations that affect the internal validity of the results. The study was unpowered to detect further differences between male and female participants that might impact SF. Furthermore, the questionnaires used in the study have been validated in Spanish but have not been culturally adapted for the Mexican population. Missing data for some variables reached up to 20%, and no imputation was performed. Lastly, all the questionnaires used were self-reported, which may introduce information, recall, and social desirability biases.

Conclusions

The study was conducted on a well-defined group of RA patients, reflecting real-life outpatients. All participants underwent comprehensive standardized rheumatologic assessments, including evaluations of their physical and mental health, as well as their perceptions related to COVID-19. These assessments were crucial to achieving the study’s objectives and bolstering both the internal and external validity of the findings. We observed a disproportionate burden of ISF among women with RA during COVID-19 compared to RA male participants. Male sex, lesser fatigue, and cohabitation with the couple were protective against ISF. Regardless of the prevalent use of teratogenic medications, contraceptive use was suboptimal.

Patient-centered care is considered the best healthcare model for patients with rheumatic diseases. Patients with RA have expressed unmet SH and RH needs, and they want their rheumatologists to address these needs in a holistic manner. As specialists, there is an opportunity for research to develop evidence-based SH and RH care strategies that take into consideration the values, preferences, and life circumstances of patients. It’s important to incorporate biopsychosocial approaches to data analysis, especially among populations typically underrepresented in the scientific arena.

Supporting information

S1 Appendix. STROBE checklist for cross sectional studies.

(PDF)

pone.0305831.s001.pdf^{(117.1KB, pdf)}

S2 Appendix. COVID-19 survey.

(PDF)

pone.0305831.s002.pdf^{(295.2KB, pdf)}

Data Availability

All relevant data are within the manuscript and its Supporting Information files. The complete data bases are not openly available, as they compromise patient identification and are considered sensitive information. The study analyzed data from outpatients from a single center in Mexico City (information regarding the single center can be deduced from co-authors' data). Patients' information includes data related to their perceived sexual and reproductive health and rheumatic disease biography. Because of the above reasons, we consider it unethical to put the data in a public repository or supporting information files. Our complete data are available from the corresponding author upon reasonable request and with our local IRB's approval. Data requests can also be placed with the chair of the Research Ethics Committee, Dr. Sergio C. Hernández Jiménez, via e-mail at: sergio.hernandezj@incmnsz.mx.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0305831.r001

Decision Letter 0

Milad Khorasani

12 Feb 2024

PONE-D-23-10059Sexual and reproductive health in Mexican patients with rheumatoid arthritis during the COVID-19 pandemic: A comprehensive approach from the biopsychosocial path.PLOS ONE

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Reviewer #1: Yes

Reviewer #2: Partly

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: I have had the opportunity to review the manuscript entitled “Sexual and reproductive health in Mexican patients with rheumatoid arthritis during the COVID-19 pandemic: A comprehensive approach from the biopsychosocial path. “ which seems to me to address a relevant, relatively unexplored topic that would be very useful in the comprehensive clinical approach to patients with rheumatoid arthritis, and which seems appropriate to be published in Plos One.

However, although the authors approach the study phenomenon with a pertinent methodological approach, I consider that the manuscript must be improved in a series of aspects of form and substance in order to be accepted.

Below, I expose this series of aspects that I consider should be corrected or refuted with solid scientific arguments by the authors:

First of all, I recommend that the manuscript be reviewed and corrected by a native English speaker, since there are some paragraphs that are difficult to understand due to the writing style used.

Title and Abstract:

A first observation is the absence of correlation or inconsistency between the title and the actual content of the study. The title emphasizes the relevance of linking the central phenomena studied with the concurrence of the SARS-Covid 2 pandemic, however, while reading the manuscript I did not find any solid connection to justify these relationships, except the temporal concurrence of the conducting the study with the pandemic, this leads me to the following question:

Did the authors justify that the presence of the pandemic would have an effect on the sexual and reproductive health of patients with RA? In my opinion, I consider that in order to justify the inclusion of this factor in the title, a comparison of the behavior of the dependent variables of sexual function or health should have been carried out before or after the end of the pandemic.

The title also gives weight to the phenomenon of “reproductive health”, however this variable is barely explored or is explored with unstructured measurement instruments, since the instruments used for the core part of the study (sexual function) are specifically focused. to the domain of function (not health, which is broader from the point of view of semantic content) sexual, not reproductive.

Additionally, from the title and throughout the manuscript the authors use “sexual health” and “sexual function” interchangeably as synonyms, which are not exactly synonymous terms. I consider that for scientific accuracy the authors should standardize the concepts used throughout. of the manuscript.

Material and methods:

A fundamental problem is the risk of selection bias that the study has in relation to the population included, since the patients studied were defined as having RA “based on the criteria of the treating rheumatologist.” Since its verification does not impose much additional effort to carry out the study, it is currently very difficult to justify a research project in RA based on patients who have not met the EULAR/ACR classification criteria. If it is not possible to modify it, this aspect (potential selection bias) should be included and discussed in the limitations of the study.

An important question to evaluate the appearance of measurement biases: Were the various instruments used, in addition to having been translated into Spanish, transculturated for the Mexican population?

In the paragraph dedicated to the operational definition of the sexual function variable in men: Were the cut-off points defined to categorize the presence of impaired sexual function arbitrary definitions made by the authors for the purposes of the study?; Or have they been previously validated?

In this same paragraph,: given that the acronym ISF ¿meaning impaired sexual function? is the first time it is used in the manuscript, it should be expressed non-acronymized, followed by its acronym in parentheses. The same observation applies to the SF acronym in the subtitle of this paragraph.

Another important point that the authors should reflect on is that the instrument used to evaluate sexual function in men has the specific objective of evaluating the phenomenon of erectile dysfunction, which, although similar, is not exactly the same as sexual function. Depending on sexual preference, a person could have decreased erectile function, but be sexually satisfied with this degree of erectile function. This aspect is also susceptible to being included in the limitations of the study.

An important aspect is that in the Methods section the variable “(past or present) sexual discomfort” is not operationally defined, althaugh is used repeatedly in the results section.

Discussion:

It seems too extensive to me, covering aspects of descriptive information of data that are not relevant to the fundamental aspect of the study: the factors associated with altered sexual health in patients with RA, which only occupies 1.5 of the 5.5 pages dedicated to this section of the manuscript.

Since it was carried out on a population from the same country, the authors should include in the introduction and discussion the paper: Alvarez-Nemegyei J, Cervantes-Díaz MT, Avila-Zapata F, Marín-Ordóñez J. Pregnancy outcomes before and after the onset of rheumatoid arthritis. Rev Med Inst Mex Seguro Soc. 2011 Nov-Dec;49(6):599-604, which addresses reproductive health topics in Mexican women with RA.

In relation to the results of the logistic regression analysis carried out, I consider that, instead of being presented as a Forrest-type graph presenting only the variables that reached statistical significance, it should be presented in tabular form with all the variables included in the model, each one with its OR, 95% CI and corresponding p value.

Reviewer #2: This is a very interesting manuscript that includes a subsection of the population that deserves more attention in research. I congratulate them on their efforts.

there are some topics though that I think could improve the manuscript:

In general, The authors indicate that the variables that are affected by RA include non SRH factors. However there are measures that are reported that are more psychosocial factors: The HADS (anxiety and depression), the RAPID-3 (disease activity/severity), the EQ-5D (health related-quality of-Life), the FACIT-F (fatigue) (which I do understand is part of the listed ´biopsychosocial path´, however this can be simplified.

Please use ´participants´ not ´patients´ throughout.

Title: should better reflect what is being studied/found in a more simplified way: one example could be Psychosocial factors associated with sexual function of male and female Rheumatoid Arthritis patients of a. xxxx hospital in Mexico City (or something to that effect)

Abstract:

The writing of the abstract can be improved, especially in the results section to correctly describe results.

What is impaired SF? The defintion is not adequate to understand what you present in results.

The dates seem to be missing when the study was undertaken.

What is ´multiple logistic regression´? Do you mean Multivariable? You do not present multivariable results, nor do you indicate what is being controlled for. You present bivariable results (at least in the abstract…). Were there no significant results with multivariable? If so this is important to state.

In the results section, the results need to be presented more clearly. Example: I do not understand this sentence: ´ Overall, 49.6% of the patients referred to the current family planning method, and 89.7% had children, with a median of 2´.

The measures that are undertaken with males and females (FSFI, satisfaction) should be presented by sex.

It wouldn´t be that ´erectile dysfunction was present in 29.4% of males, but instead 29.4% of males reported erectile dysfunction. You´re are not actually measuring the erectile dysfunction but instead the report.

´Male` is not a gender, it is sex.

The OR and p values can be truncated at two numbers after the decimal.

% results should be presented with OR values.

Could there be confounding variables that need to be controlled for (age)?

Conclusions:

You cannot conclude that RA compromises SRH, you have no control group (non RA). All you can say that some psychosocial factors were found in individuals with RA, and there were differences of participant sex

Introduction:

You state that WHO recommends using SH (which includes RH), yet you continue to use SRH. Why is this?

Authors write: ´RH in RA patients has focused on reduced fertility (30-35) which has been related to the disease process itself [30], therapy [29], gonadal dysfunction [36], physicians’ advice [30, 31], and individual decisions [30, 31]. ´ what do you mean by physicians´advice and individual decisions?

This last sentence and the following starting line 86 need to be put together into one. You´ve already said reduced fertility (subfertility should be called ´infertility´ . This one item (infertility) can be included in the previous sentence as ´infertility´ and put the citations together.

*Methods*

The study was undertaken between 2020 and 2022. Were there still covid instruments being included in 2022?

No need to cite STROBE and include it in as supplementary material. I believe it is just the journal that needs this when submitting.

The methods include qualitative research. These results are not reflected in the abstract.

How were the quantitative questionnaires administered? Paper format? Electronic?

In the definitions and groups (what is ´groups´?) you only mention impaired sexual function for males and females. This is not a ´reproductive health´ measure per se, but instead by definition, a sexual health measure. Perhaps think about this (as these are you outcome variables) when reworking your title and focus in your abstract.

Sample size: if you only needed 151 patients, why did you include more than 100 more?

what is the overall population estimated with RA in CDMX?

Results seem to be expressed (at least in the abstract as OR not AOR or aOR which would be adjusted).

Furthermore, you do not indicate what you are adjusting for (other than RAPID-3), but surely age must be a confounder when dealing with sexual function (although it is shocking to me- the literature says that starting late 20´s early 30s, women´s sexual function may start to decline!)

Results:

NO need to duplicate in written results what is in the table. This section could be rearranged, considering the recommendations below of the tables.

What is ´middle aged female? This is a vague definition that can mean a lot of things to different people. Median and IQR should be used for age.

The table 1 needs some better structure. For example, many variables are presented with mean or medians? This needs to be defined better. But there are variables like Religious beliefs (what does this mean? Is it ANY religious beliefs? Is it being spiritual? Being in a relationship is the same. So it should be set up as categories for some of these variables: Employment (formal is one category and informal is another category), etc.

Table 2 is perhaps important, but these variables need to described in light of your outcome variables (and included in the abstract and better woven into the paper). Otherwise it´s just information that is hanging in the air. Are the anxiety and depression scales ONLY covid related? Why are they not part of other tables? Where these

Now I see RH results (these seem to be missing sadly from a lot of the paper)

For the results section- I would organize like this:

Table 1: demographic characteristics with medians(IQR), means(SD) and categories correctly presented

Table two: Outcome variables presented of impaired SF and non-impaired SF(columns) against demographic variables (rows). The covid variables should just be other non-outcome variables but labeled correctly.

Table three: OR with significant variables found in table two.

Discussion:

This should be in sync with the more developed results. As it is, it is quite long and wordy, but does not need to be. You need to decide if COVID is going to be main non-outcome variables or not (depending on results), this is not even mentioned in the first paragraph of the discussion.

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2024 Aug 26;19(8):e0305831. doi: 10.1371/journal.pone.0305831.r002

Author response to Decision Letter 0

26 Feb 2024

Responses to reviewers

Reviewer #1

I have had the opportunity to review the manuscript entitled “Sexual and reproductive health in Mexican patients with rheumatoid arthritis during the COVID-19 pandemic: A comprehensive approach from the biopsychosocial path “which seems to me to address a relevant, relatively unexplored topic that would be very useful in the comprehensive clinical approach to patients with rheumatoid arthritis, and which seems appropriate to be published in Plos One.

Response. We appreciate the reviewer's comments.

Below, I expose this series of aspects that I consider should be corrected or refuted with solid scientific arguments by the authors:

First of all, I recommend that the manuscript be reviewed and corrected by a native English speaker, since some paragraphs are difficult to understand due to the writing style used.

Response. The manuscript was already reviewed by an editing service (Grammarly business edition). It has been re-reviewed.

Title and Abstract:

The title also gives weight to the phenomenon of “reproductive health,” however, this variable is barely explored or is explored with unstructured measurement instruments since the instruments used for the core part of the study (sexual function) are specifically focused. to the domain of function (not health, which is broader from the point of view of semantic content) sexual, not reproductive.

Response. We have updated the title of the manuscript to highlight the main results, which are the factors associated with impaired sexual function, and omitted the reference to the COVID-19 pandemic. The second reviewer has a similar request. The title has been updated to “Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis.”

Response. We agree with the reviewer that sexual health and sexual function are not synonyms; in fact, sexual function contributes to sexual health. We have been more accurate about the terms used throughout the manuscript. In particular, in the material and methods and results sections, the term "sexual function" is preferred over the term sexual health, consistent with the outcome of interest, that is, impaired sexual function, defined with appropriate tools. However, the reviewer might also have found the term sexual health throughout the text when appropriate and when mentioned by other authors.

Material and methods:

Response. We disagree with the reviewer. 2010 EULAR/ACR criteria are classification criteria and should not be used for RA diagnosis (Aletaha et al, 2010). As the authors state, “While classification criteria are potentially adopted for use as aids for diagnosis, the focus of this endeavor was not on developing diagnostic criteria or providing a referral tool for primary care physicians…The criteria do not remove the onus on individual physicians, especially in the face of unusual presentations, to reach a diagnostic opinion that might vary from the assignment obtained using the criteria…. Much like other classification criteria, clinicians may be able to diagnose an individual who has not met the classification criteria definition or who has features that are not a component of the classification criteria.” Aletaha et al. also stated in their manuscript that “there is no gold standard for RA diagnosis.” Most of the time, in daily practice, rheumatologists establish the diagnosis based on the combination of clinical signs/symptoms, available clinical tests, and knowledge about the epidemiology of the area. (Aggarwal R et al. Distinctions Between Diagnostic and Classification Criteria? Arthritis Care Res (Hoboken). 2015 July ; 67(7): 891–897. doi:10.1002/acr.22583). Finally, it is generally accepted that the diagnosis of rheumatic diseases should be individualized because the classification criteria could not include all the phenotypes of diseases, including unusual features or presentations. Diagnosed by board-certified rheumatologists has been used (Young KA et al. Arthritis Rheum 2013).

Response. FSFI and IIEF have not undergone transcultural adaptation for the Mexican population. We have addressed it as a limitation.

Response. We used previously published cut-offs.

In this same paragraph, given that the acronym ISF ¿meaning impaired sexual function? This is the first time it is used in the manuscript. It should be expressed non-acronymized, followed by its acronym in parentheses. The same observation applies to the SF acronym in the subtitle of this paragraph.

Response. We are sorry for the mistake. We have reviewed the updated version to address the point raised by the reviewer.

Response. We agree with the reviewer and have addressed the point as a limitation.

An important aspect is that in the Methods section, the variable “(past or present) sexual discomfort” is not operationally defined, although it is used repeatedly in the Results section.

Response. We agree with the reviewer, and in the updated version, we provide an operational definition of sexual discomforts and a reference.

Discussion:

Response. We have updated the discussion section.

Response. The suggestion has been adopted.

Response. The suggestion has been adopted. In addition to the Forrest-type graph (we have conserved as it summarizes the test-based backward selection that was used to define the final model), we have added Table 3, which presents OR and aOR (required by one reviewer) for all the variables included in the model.

Reviewer #2

This is a very interesting manuscript that includes a subsection of the population that deserves more attention in research. I congratulate them on their efforts.

there are some topics, though, that I think could improve the manuscript:

Response. We appreciate the reviewer's comments.

In general, The authors indicate that the variables that are affected by RA include non SRH factors. However, there are measures that are reported that are more psychosocial factors: The HADS (anxiety and depression), the RAPID-3 (disease activity/severity), the EQ-5D (health related-quality of-Life), the FACIT-F (fatigue) (which I do understand is part of the listed ´biopsychosocial path´, however this can be simplified.

Response. We have tried to provide an updated version that is more accurate and highlights relevant results.

Please use ´participants,´ not ´patients´ throughout.

Response. We have adopted the suggestion, particularly in the methods and results sections.

Response. We have followed the reviewer's suggestion and updated the title to "Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis."

Abstract:

The writing of the abstract can be improved, especially in the results section to correctly describe results.

Response. We have updated the abstract to address the reviewer´s point.

What is impaired SF? The definition is not adequate to understand what you present in the results.

Response. We have provided a better definition of ISF.

The dates seem to be missing when the study was undertaken.

Response. We have updated the dates.

Response. We have updated the term multiple to the appropriate term, multivariable. We have updated the section to make the results from the multivariable regression analysis more evident.

In the results section, the results need to be presented more clearly. Example: I do not understand this sentence: Overall, 49.6% of the patients referred to the current family planning method, and 89.7% had children, with a median of 2´.

Response. We have updated the whole section.

The measures that are undertaken with males and females (FSFI, satisfaction) should be presented by sex.

Response. The suggestion has been adopted.

Response. The reviewer is right, we have updated the abstract.

´Male` is not a gender, it is sex.

Response. We have updated the term.

The OR and p values can be truncated at two numbers after the decimal.

Response. The suggestion has been adopted.

% results should be presented with OR values.

Response. We are unsure about what the reviewer is asking for, however, we have added OR for the explanatory variables of interest in table 3.

Could there be confounding variables that need to be controlled for (age)?

Response. We added age as a confounder variable in Table 3.

Conclusions:

Response. The conclusions have been updated.

Introduction:

You state that WHO recommends using SH (which includes RH), yet you continue to use SRH. Why is this?

Response. We agree with the reviewer. We have omitted the acronym SRH and used/assessed as recommended, SH and RH throughout the text.

Response. We have updated the sentence to improve clarity.

Response. We have updated the sentence according to the reviewer´s suggestion.

*Methods*

The study was undertaken between 2020 and 2022. Were there still covid instruments being included in 2022?

Response. The COVID-19 survey was administered to all the participants.

There is no need to cite STROBE and include it as supplementary material. I believe it is just the journal that needs this when submitting.

Response. We are including STROBE as the journal recommends it should be used in observational studies.

The methods include qualitative research. These results are not reflected in the abstract.

How were the quantitative questionnaires administered? Paper format? Electronic?

Response. Data related to RH in the abstract was derived from the semi-structured interview. Questionnaires were administered in paper format. It has been updated in the corresponding section.

Response. We have renamed the paragraph as “Definitions” and added one more definition (“sexual discomforts”) as requested by the second reviewer. We have updated the abstract, the manuscript, and the title to highlight factors associated with the outcome of interest, ISF in males and females.

Sample size: if you only needed 151 patients, why did you include more than 100 more?

what is the overall population estimated with RA in CDMX?

Response. The sample size estimation was based on a hypothesis considering the RAPID-3 effect size odds ratio of 2.5 in a non-normal distribution, using a one-tailed test, 5% significance level, and 80% power. However, we assumed other factors could be associated with ISF, and we might need a bigger sample size to guarantee suffi

Attachment

Submitted filename: Responses to reviewers.docx

pone.0305831.s003.docx^{(26.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0305831.r003

Decision Letter 1

Milad Khorasani

1 Apr 2024

PONE-D-23-10059R1Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis.PLOS ONE

Dear Dr. Pascual-Ramos,

==============================

Please submit your revised manuscript by May 16 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Milad Khorasani, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: I consider that the authors have carried out all the suggested corrections, or have refuted in a solid argumentative manner those with which they did not agree, so I consider that the manuscript could be accepted.

However, before being accepted there are some specific aspects that require correction or clarification:

The aOR values of the predictor variables that were significant in the logistic regression model that are mentioned in the abstract, in the text of the results and in Figure 3 do not coincide with those shown in Table 3. In fact, none of the aOR and p values in the corresponding column are significant.

There appears to be an error in placing the value of the decimal point in the confidence interval of the FACIT variable in Figure 3, it is mentioned as (0.92-0.10), when in reality its correct value appears to be (0.92-1.00).

I consider that once these specific situations have been corrected or clarified, the article can be accepted.

Reviewer #2: Thank you for the opportunity to review this manuscript. Although it is much improved from the last version, I still feel there are things that can be improved upon.

Abstract

- In the intro (line 83) you say there are characteristics for the LA region (greater female: male ratio and younger age at presentation, although you show this in the intro (with a citation), this sentence alone in the abstract is a bit distracting. Perhaps an opening statement should be that RA affects sexual function or something more general as you are not focused on comparing LA patients to others in the world but instead the affects on

- The abstract still indicates ´patients´ (the term participants was recommended to use). No need to mention more than the term ´Methods´ in the subsection.

- Idncate in the methods section if questionnaires were provider-administered? Study-team administered? self-administered?

- No need to say 1st and 31st (you can just say September 1 yyyy -January 31 yyyy (same with Methods section in body of document)

- Descriptive statistics and multivariable logistic regression analysis were used. (were used to…? (to study x factors related to y)

- What is FACIT-F.? Please don´t use acronyms without defining.

- The conclusion needs to be more explicit. X, y and z were found to be associated with ISF…. We recommend….or a conclusion of the findings.

Introduction:

- You cite Caucasians and which sex is most affected (please correct to females and males as gender is not as much a factor as sex is)- can you find a citation that looks at the F:M ratio among Latin Americans?

Methods

- Normally the ethics section goes at the end of the Methods section

- It is not clear (line 136) who applied the paper survey. They say administered, how was that administration (this should be discussed in the limitations section as well as any way you apply a survey there are bias’s to how people respond)

- Definitions subtitle could be better titled as ´Measures´

- ´Statistical analysis´ subtitle could be better called ´Statistical Analyses´ as there are more than one.

- I think the terms univariable/multivariable or univariate/multivariate should be homogenized. Right now, there is univariate/multivariable.

- What was the adjustment in the aOR for? (i.e. what did you adjust for)

- Missing data : (line 222) is this only per question? Or if someone said I don´t want to answer to one question then none of their questions were included?

- Line 226´A value of p<0.05 was considered statistically significant.´ seems wrongly placed

Results

- Line 230 missing data needs to be better explained as above (and no need to repeat if this has already been explained in methods)

- Table 1: what are ´self-referring Catholics and self-referring non-religious?´ is this self-reported? If so, could probably drop it as would think all religion is self-reported?

- This table could be better presented as

Variable N=xxx

Category n % or median(IQR)

Category n

category n

And some variables could be kept as one (e.g. age)

Please indicate what the * stands for

Table 1 should be presented with male and females as well:

All participants Male participants Female participants

Variable N=xxx % or median(IQR) (should be denoted as median if you present median) N=xxx % or median(IQR) (should be denoted as median if you present median) N=xxx % or median(IQR) (should be denoted as median if you present median)

Category n

category n

Please don´t repeat written results if they are in the table, unless they are some of the main results. The written results can be cut down a lot I think.

Table three could be presented as two extra columns of table 2 (in the same format as my suggestion for Table 1 above), as its best to be able to see OR and aOR against %. Please define what the current table 2 p-values are describing.

Figures 1 and 2: make sure data is not repeated in tables. If it is, please eliminate figures.

Figures 3 (it´s not titled but I think it is figure 3) doesn´tadd much to the data as this is already presented in the table.

Was age added in the model as an adjusting factor? This should be explained in the methods perhaps.

Discussion.

The first paragraph should highlight a few findings from your analyses and the following paragraphs explain these findings further and compare to other research in the same paragraph.

Please check grammar throughout but (line 340, 341 especially)

Your discussion on male participants (lines aprox. 350) is biased because of your low sample size, this should be highlighted.

Fully discuss limitations (some ideas above)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: José Alvarez-Nemegyei

Reviewer #2: No

**********

Attachment

Submitted filename: RA_r1notes.docx

pone.0305831.s004.docx^{(19.7KB, docx)}

PLoS One. 2024 Aug 26;19(8):e0305831. doi: 10.1371/journal.pone.0305831.r004

Author response to Decision Letter 1

8 Apr 2024

Reviewer #1

I consider that the authors have carried out all the suggested corrections, or have refuted in a solid argumentative manner those with which they disagreed, so I consider that the manuscript could be accepted.

Response. We appreciate the reviewer's comments.

However, before being accepted, there are some specific aspects that require correction or clarification:

Response. In the previous revision, the reviewer suggested a table (currently table 3) with OR and aOR (95% CI and p values) from all the variables included in the logistic regression model, and not only those that reached statistical significance. We have updated the title of Table 3 to better align with the information provided. In addition, aORs presented in the results section of the abstract are aligned with data from Figure 3. Both summarize only the variables from the multivariable regression model that ended up reaching statistical significance.

I consider that once these specific situations have been corrected or clarified, the article can be accepted.

Response. We are sorry for the mistake. We have updated the Figure 3.

Reviewer #2:

Thank you for the opportunity to review this manuscript. Although it is much improved from the last version, I still feel there are things that can be improved upon.

Abstract

Response. We have adopted the suggestion and proposed an updated version.

- The abstract still indicates ´patients´ (the term participants was recommended to use). No need to mention more than the term ´Methods´ in the subsection.

Response. We have adopted both suggestions.

- Indicate in the methods section if questionnaires were provider-administered? Study-team administered? self-administered?

Response. We have updated the abstract and clarified that questionnaires were self-administered.

- No need to say 1st and 31st (you can just say September 1 yyyy -January 31 yyyy (same with Methods section in the body of document)

Response. We have adopted the suggestion.

- Descriptive statistics and multivariable logistic regression analysis were used. (were used to…? (to study x factors related to y)

Response. We have updated the sentence to adopt the suggestion.

- What is FACIT-F.? Please don´t use acronyms without defining it.

Response. We apologize. We have defined FACIT-F.

- The conclusion needs to be more explicit. X, y and z were found to be associated with ISF…. We recommend….or a conclusion of the findings.

Response. We have updated the conclusions following the reviewer´s recommendation.

Introduction:

Response. We have adopted the suggestion. Ref 38 is appropriately cited. Although the paper focuses on treatment, it describes the data from 1093 patients from 14 LATAM countries, of whom 85.3% were females.

Methods

- Normally the ethics section goes at the end of the Methods section

Response. The ethics section was moved to the end of the methods section.

Response. All questionnaires were self-administered, and this information was updated as suggested. We have added biases associated with self-reported questionnaires to the limitations section.

- Definitions subtitle could be better titled as ´Measures´

Response. We have updated the subtitle.

- ´Statistical analysis´ subtitle could be better called ´Statistical Analyses´ as there are more than one.

Response. We have updated the subtitle.

- I think the terms univariable/multivariable or univariate/multivariate should be homogenized. Right now, there is univariate/multivariable.

Response. We have adopted the suggestion.

- What was the adjustment in the aOR for? (i.e. what did you adjust for)

Response. We have updated the information required in the statistical analyses section.

- Missing data : (line 222) is this only per question? Or if someone said I don´t want to answer to one question then none of their questions were included?

Response. We have updated the paragraph.

- Line 226´A value of p<0.05 was considered statistically significant´ seems wrongly placed

Response. We have updated the paragraph.

Results

- Line 230 missing data needs to be better explained as above (and no need to repeat if this has already been explained in methods)

Response. We have omitted the information from the results section and provided a better explanation in the methods section.

- Table 1: what are ´self-referring Catholics and self-referring non-religious?´ is this self-reported? If so, could probably drop it as would think all religion is self-reported?

Response. We agree with the reviewer and have omitted the information.

- This table could be better presented as

Variable N=xxx

Category n % or median(IQR)

Category n

category n

And some variables could be kept as one (e.g. age)

Please indicate what the * stands for

Table 1 should be presented with male and females as well:

All participants Male participants Female participants

Category n

category n

Response. We have modified Table 1 and incorporated all the suggestions.

Please don´t repeat written results if they are in the table, unless they are some of the main results. The written results can be cut down a lot I think.

Response. We have reviewed the whole section, and currently, there are no results duplicated in the text and the tables or figures.

Table three could be presented as two extra columns of table 2 (in the same format as my suggestion for Table 1 above), as its best to be able to see OR and aOR against %.

Response. Table 3 responds to reviewer one request to present OR and aOR for ALL the variables included in the multivariable logistic regression model (instead of presenting only those that ended up being statistically significant, which are summarized in Figure 3). For this reason, Table 3 should remain.

Please define what the current table 2 p-values are describing.

Response. Table 2 has been updated, and the reviewer's request has been included in the text.

Figures 1 and 2: make sure data is not repeated in tables. If it is, please eliminate figures.

Response. In the current version, there are no repeated data.

Figure 3 (it´s not titled, but I think it is figure 3) doesn t add much to the data as this is already presented in the table.

Response. We consider Figure 3 should remain as it presents the results (variables that ended up being statistically significant) from the multivariable regression analysis. These are not presented elsewhere.

Was age added in the model as an adjusting factor? This should be explained in the methods perhaps.

Response. Yes, it was, and we have clarified it.

Discussion.

The first paragraph should highlight a few findings from your analyses and the following paragraphs explain these findings further and compare to other research in the same paragraph.

Response. We have organized the discussion as suggested.

Please check grammar throughout but (line 340, 341 especially).

Response. We have used an editing service (Grammarly Business).

Your discussion on male participants (lines aprox. 350) is biased because of your low sample size, this should be highlighted.

Response. We agree with the reviewer and have updated the paragraph. We have also assumed that the number of male participants is a limitation of the study.

Fully discuss limitations (some ideas above)

Response. We have updated the limitations section.

Attachment

Submitted filename: Responses to reviewers.docx

pone.0305831.s005.docx^{(21.2KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0305831.r005

Decision Letter 2

Milad Khorasani

28 May 2024

PONE-D-23-10059R2Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis.PLOS ONE

Dear Dr. Pascual-Ramos,

Please submit your revised manuscript by Jul 12 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Milad Khorasani, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #1: (No Response)

Reviewer #3: Could authors explain the differences regarding a previous paper that explored the prevalence of sexual dysfunction in Mexican women with rheumatoid arthritis (Rojo-Contreras et al. Healthcare (Basel) 2022 Sep 21;10(10):1825. doi: 10.3390/healthcare10101825) focusing on the associated factors of sexual dysfunction to establish the main differences regarding this. In addition to see for the main contributions of the study carried out, author´s should incorporate into the Discussion section the advantages, disadvantages and areas of opportunity for the internal and external validity of the study carried out.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Jose Alvarez-Nemegyei

Reviewer #3: No

**********

PLoS One. 2024 Aug 26;19(8):e0305831. doi: 10.1371/journal.pone.0305831.r006

Author response to Decision Letter 2

30 May 2024

Responses to reviewers

Could authors explain the differences regarding a previous paper that explored the prevalence of sexual dysfunction in Mexican women with rheumatoid arthritis (Rojo-Contreras et al. Healthcare (Basel) 2022 Sep 21;10(10):1825. doi: 10.3390/healthcare10101825) focusing on the associated factors of sexual dysfunction to establish the main differences regarding this.

Response. We have included the reference and updated the discussion section to highlight the similarities and differences between both studies.

In addition to see for the main contributions of the study carried out, author´s should incorporate into the Discussion section the advantages, disadvantages and areas of opportunity for the internal and external validity of the study carried out.

Response. In the limitations section, we discussed the internal and external validity of the results. In the conclusion, we summarized the study's advantages and areas of opportunity for future research.

Attachment

Submitted filename: Responses to reviewers.docx

pone.0305831.s006.docx^{(13.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0305831.r007

Decision Letter 3

Milad Khorasani

6 Jun 2024

Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis.

PONE-D-23-10059R3

Dear Dr. Pascual-Ramos,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Milad Khorasani, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #3: Authors have attended the comments and suggestion, and accordingly them the manuscript in the Discussion section was improved.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

**********

PLoS One. doi: 10.1371/journal.pone.0305831.r008

Acceptance letter

Milad Khorasani

16 Aug 2024

PONE-D-23-10059R3

PLOS ONE

Dear Dr. Pascual-Ramos,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

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on behalf of

Dr. Milad Khorasani

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Appendix. STROBE checklist for cross sectional studies.

(PDF)

pone.0305831.s001.pdf^{(117.1KB, pdf)}

S2 Appendix. COVID-19 survey.

(PDF)

pone.0305831.s002.pdf^{(295.2KB, pdf)}

Attachment

Submitted filename: Responses to reviewers.docx

pone.0305831.s003.docx^{(26.1KB, docx)}

Attachment

Submitted filename: RA_r1notes.docx

pone.0305831.s004.docx^{(19.7KB, docx)}

Attachment

Submitted filename: Responses to reviewers.docx

pone.0305831.s005.docx^{(21.2KB, docx)}

Attachment

Submitted filename: Responses to reviewers.docx

pone.0305831.s006.docx^{(13.7KB, docx)}

Data Availability Statement

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PERMALINK

Biopsychosocial factors are associated with impaired sexual function in Mexican patients with rheumatoid arthritis

Loraine Ledón-Llanes

Irazú Contreras-Yáñez

Guillermo Arturo Guaracha-Basáñez

Salvador Saúl Valverde-Hernández

Maximiliano Cuevas-Montoya

Ana Belén Ortiz-Haro

Virginia Pascual-Ramos

Roles

Abstract

Background

Methods

Results

Conclusions

Introduction

Materials and methods

Setting and participants

Study design, study assessments, and data collection

Measures

ISF in male participants

ISF in female participants

RA-disease activity categories

Sample size calculation

Statistical analyses

Ethics

Results

Overall population characteristics

Table 1. Socio-demographics, RA-related, mental-health-related, and COVID-19-related characteristics in the participants enrolled in the study, female and male participants.

SH in the entire population

Fig 1. Sexual function indices-related information in females and males with RA.

RH in the entire population

Comparison of participants with and without ISF

Table 2. Comparison of sociodemographic, RA-related, mental health-related, and COVID-19-related characteristics between participants with ISF and their counterparts.

Fig 2. Comparison of ISF indices-related domains between patients with ISF and their counterparts.

Factors associated with ISF

Table 3. OR and aOR (95% CI and p-value) for all the variables included in the multivariable logistic regression analysis.

Fig 3. Results from the multivariable logistic regression analysis: Significant factors associated with ISF.

Discussion

Conclusions

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Milad Khorasani

Roles

Author response to Decision Letter 0

Decision Letter 1

Milad Khorasani

Roles

Author response to Decision Letter 1

Decision Letter 2

Milad Khorasani

Roles

Author response to Decision Letter 2

Decision Letter 3

Milad Khorasani

Roles

Acceptance letter

Milad Khorasani

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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