Health Professionals’ Approaches to Support Patient Diversity in the Assessment of Vaginismus: A Critical Feminist Qualitative Study for Inclusive Care

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

• “However, accessing…” – belongs to the previous paragraph.
• “the lacking social awareness..” isn’t grammatically sound.
• “Current research” – no need for “The”.
• The researchers have not acknowledged in their “Reflexivity” that they are social constructionists which biases their findings within a social constructionist framework. I know it’s the point, but social constructionism purposefully seeks structural power imbalance even when it might not be the case. It’s not a neutral standpoint, basically.
• I would say that theme 1.2. is more “mixed findings” – there is variation in healthcare management with respect to ethnicity and religious diversity.
• I would say the same for theme 1.3. It appears that there are some HPs engaging in management with respect to specific disability needs.
• The information provided does not support “Marginalisation of gender diverse people’s treatment goals” – it’s more to do with the limited number of gender diverse patients that the HPs come in to contact with.
• It could be argued that reservations… reflects Western ethnocentricity, but it also reflects a lack of confidence or knowledge or concern about offence etc., rather than ethnocentricity per-se.
• Epistemologically, I fundamentally disagree with “decolonisation”. I appreciate that Black and Indigenous individuals could have a different profile of needs that require a different healthcare approach (I don’t wish to speak for them – and this could be an assertion of colonialism in of itself), but this comes from a lack of knowledge and familiarity as well as the difficulties that arise from trying to bridge these gaps, rather than anything else (although historically this was different). It is an incredibly complex issue that isn’t simply resolved by asserting colonialism because ultimately it doesn’t solve anything. Knowledge maybe needed to understand the needs of the groups mentioned in the study, but by the tenets of social constructionism, knowledge acquisition could be a form of colonialism in of itself. So where does that leave us?
• “most reported…” – how many? There is no evidence to support “it suggests that the educational curricula and training…. reproduced heteronormativity and cisnormativity.
• The authors appear to criticise the HPs who celebrate how lesbians appear to manage the psychological consequences of vaginismus more effectively than heterosexual couples. This is to be entirely expected considering that they share the same sexual organs Nevertheless, the authors see this as a bad thing because they think it suggests that HPs take it less seriously in lesbian couples – although there is no evidence to support this claim.
• That HPs reported reservations is also criticised and seen as an act of discrimination rather than empathising with the fact that this is likely a difficult avenue of enquiry based on very limited knowledge of how the condition impacts these groups.
• Again I don’t agree that “these are all indicative of residual continuation of Eurocentric colonial agendas…” – there is no evidence of this and therefore it is supposition. The authors should be aware, for example, that individuals with red hair are more sensitive to pain and require more anaesthetic – this is something that isn’t well known by HP because of the infrequency by which they come across individuals with red hair (1%) of the population – this is not an example of colonialism but a situation based on frequencies. With Black and Indigenous groups the issue is compounded by language and cultural differences that are not necessarily easily navigated but this is not a value judgement. Of course, these groups should have their gynaecological needs met but claiming colonialism does not resolve it. People don’t know what is for the best.
• How are HP supposed to navigate issues pertaining to religious values? Are the authors expecting HPs to engage in lengthy conversations with patients about their religious values before treatment? These could be highly individualised owing the variation of values even within religious groups.
• Issues raised in Lines 457-460 impacts all women irrespective of background.
• I would consider it a biological fact that women lose sexual desire as they get older because of reducing oestrogen. Of course, there are women who still have a sex drive at an older age but nevertheless, it is not unreasonable for HP to work on the notion to the contrary – this is not ageism but working with averages/general trends in order to facilitate decision making. That there is a majority is not a value judgement against those that fall beyond that.
• Limitations are the fact that the study actively seeks to interpret findings from a structural inequality context without considering alternative explanations.
• Ultimately – gynaecological healthcare is a problem for probably the majority of women irrespective of background. Many women are traumatised by repeated examinations and the approach of consultants in which the sexual organs are treated as if they are disconnected to a human being. The fundamental issue is sexism. The paper has utility in highlighting the needs of non-majority groups that absolutely should be addressed, but as a qualitative piece of research, there is no evidence for the assertions being made about various isms. The authors don’t really present any sort of solution either – this could be working groups of patients who can recommend approaches although this could again could be an example of othering.

Author Response

We thank the reviewer for taking the time to engage with our manuscript and providing feedback. All references to page and line numbers below are based on the revised manuscript with track changes (not the clean version).

Comment 1: “However, accessing…” – belongs to the previous paragraph.

Response 1: We thank the reviewer for this comment and have actioned it by moving ‘However, accessing…” to the previous paragraph (See ‘Introduction’ section on p. 2, line 48).

Comment 2: “the lacking social awareness..” isn’t grammatically sound.

Response 2: This wording has been changed to ‘The lack of social awareness…’ (See ‘Introduction’ section on p. 2, line 50)

Comment 3: “Current research” – no need for “The”.

Response 3: The wording has now been changed to ‘Current research’ with the word ‘The’ removed to action the reviewer’s feedback (See ‘Introduction’ section on p. 2, line 61).

Comment 4: The researchers have not acknowledged in their “Reflexivity” that they are social constructionists which biases their findings within a social constructionist framework. I know it’s the point, but social constructionism purposefully seeks structural power imbalance even when it might not be the case. It’s not a neutral standpoint, basically.

Response 4: We thank the reviewer for this comment on reflexivity and author positioning. While the study is informed by a social constructionist-informed CFPS framework, the authors do not position themselves as exclusively aligned with a single epistemological identity. To address this feedback, the reflexivity subsection has been revised to include the authors’ health sociology backgrounds and how these potentially strengthen and limit or bias analysis, in line with established qualitative reflexivity guidance (See ‘Researcher reflexivity’ subsection on p. 5, lines 203–204).

We have also added the following clarification on neutrality using track changes (See ‘Theoretical frame’ subsection, p. 3, lines 105–107): “This study is informed by a critical feminist poststructuralist (CFPS) lens which does not claim positivist neutrality. Instead of viewing the healthcare system as inherently neutral, poststructuralism examines the possible power structures that contribute to the disempowerment and healthcare inequity of certain groups”

References to the CFPS lens (e.g., “through a CFPS lens”) have also been retained throughout the discussion to maintain transparency of interpretation.

Comment 5: I would say that theme 1.2. is more “mixed findings” – there is variation in healthcare management with respect to ethnicity and religious diversity.

I would say the same for theme 1.3. It appears that there are some HPs engaging in management with respect to specific disability needs.

Response 5: We appreciate the reviewer’s observation. Both Theme 1.2 and Theme 1.3 have been revised with track changes to include “with mixed findings” to accept the reviewer’s feedback (See Results section, p. 8, lines 268–269 and p. 9, line 318).

Comment 6: The information provided does not support “Marginalisation of gender diverse people’s treatment goals” – it’s more to do with the limited number of gender diverse patients that the HPs come in to contact with.

Response 6: We thank the reviewer for this comment. The subtheme’s name raised by the reviewer has been revised to ‘Limited representation of gender diverse people’s treatment goals’ after discussion and consensus with all authors as per qualitative methodological processes (See p. 10, theme 2.2 name, line 364). This has also been revised in the Abstract section (See p. 1, line 30).

Comment 7: It could be argued that reservations… reflects Western ethnocentricity, but it also reflects a lack of confidence or knowledge or concern about offence etc., rather than ethnocentricity per-se.

Response 7: We appreciate the reviewer highlighting alternative explanations such as lack of confidence or knowledge. We agree these factors are relevant and have now been more explicitly incorporated (See ‘Discussion and directions for future research and practice’ section, p. 12, lines 474–481).

We have retained a focus on systemic training gaps, consistent with the study’s CFPS framework, while clarifying that these interpretations are not intended to attribute individual blame but to identify areas for potential improvement in healthcare education for sensitive enquiry with diverse patients.

Comment 8: Epistemologically, I fundamentally disagree with “decolonisation”. I appreciate that Black and Indigenous individuals could have a different profile of needs that require a different healthcare approach (I don’t wish to speak for them – and this could be an assertion of colonialism in of itself), but this comes from a lack of knowledge and familiarity as well as the difficulties that arise from trying to bridge these gaps, rather than anything else(although historically this was different). It is an incredibly complex issue that isn’t simply resolved by asserting colonialism because ultimately it doesn’t solve anything. Knowledge maybe needed to understand the needs of the groups mentioned in the study, but by the tenets of social constructionism, knowledge acquisition could be a form of colonialism in of itself. So where does that leave us?

Response 8: We thank the reviewer for this epistemological reflection. The manuscript contains only about a half-paragraph (lines 502-509) linking to colonialism/decolonising approaches in the ‘Discussion and directions for future research and practice’ section. To address the reviewer’s concern about overstatement, we have softened the language from “are all indicative” to “may be indicative of residual continuation of Eurocentric colonial agendas” (See ‘Discussion and directions for future research and practice’ section, p. 12, line 502). 

We acknowledge the complexity of these issues and the role of knowledge gaps. However, current scholarship continues to document residual effects of colonialism in healthcare for some Black and Indigenous populations. Within the stated CFPS framework, critically examining such possibilities (without asserting causation) remains appropriate and can inform efforts to minimise unintended perpetuation of outdated paradigms.

Comment 9: “most reported…” – how many? There is no evidence to support “it suggests that the educational curricula and training…. reproduced heteronormativity and cisnormativity.

Response 9: Thank you for this feedback. The relevant sentences have been rewritten using track changes to strengthen the link to evidence from the results and health professionals who reported the issues in themes 1.2 and 2.1 (See ‘Discussion and directions for future research and practice’ section, p. 10, lines 385–390). 

Comment 10: The authors appear to criticise the HPs who celebrate how lesbians appear to manage the psychological consequences of vaginismus more effectively than heterosexual couples. This is to be entirely expected considering that they share the same sexual organs Nevertheless, the authors see this as a bad thing because they think it suggests that HPs take it less seriously in lesbian couples – although there is no evidence to support this claim.

That HPs reported reservations is also criticised and seen as an act of discrimination rather than empathising with the fact that this is likely a difficult avenue of enquiry based on very limited knowledge of how the condition impacts these groups.

Response 10: We appreciate this feedback and the opportunity to clarify. On review of the manuscript, we were unable to identify statements that explicitly criticise individual health professionals or attribute negative intent to their perspectives.

To address the reviewer’s concern, we have revised the following sentences with track changes (See ‘Discussion and directions for future research and practice’ section, p. 11, lines 445–448): “Consequently, participants’ perspectives that vaginismus is less straining on lesbian relationships could be explored in larger empirical studies. This can provide clearer evidence-based understanding of lesbian couple’s experiences of vaginismus to better support their needs in healthcare management.”

If the reviewer can kindly quote the specific lines perceived as criticism, we would be happy to revise or clarify further.

Comment 11: Again I don’t agree that “these are all indicative of residual continuation of Eurocentric colonial agendas…” – there is no evidence of this and therefore it is supposition. The authors should be aware, for example, that individuals with red hair are more sensitive to pain and require more anaesthetic –this is something that isn’t well known by HP because of the infrequency by which they come across individuals with redhair (1%) of the population – this is not an example of colonialism but a situation based on frequencies. With Black and Indigenous groups the issue is compounded by language and cultural differences that are not necessarily easily navigated but this is not a value judgement. Of course, these groups should have their gynaecological needs met but claiming colonialism does not resolve it. People don’t know what is for the best.

Response 11: We thank the reviewer for this perspective and the analogy provided. We do not suggest that all disparities in healthcare arise from colonialism.

To address concerns about overstatement, we have revised the wording to reflect a more cautious interpretation: “may be indicative of residual continuation of Eurocentric colonial agendas” (See ‘Discussion and directions for future research and practice’ section, p. 12, line 502).

This framing is intended to position colonial legacies as one possible contributing factor among others, consistent with the study’s CFPS framework, rather than as a definitive explanation.

Comment 12: How are HP supposed to navigate issues pertaining to religious values? Are the authors expecting HPs to engage in lengthy conversations with patients about their religious values before treatment? These could be highly individualised owing the variation of values even within religious groups.

Response 12: Thank you for this reflection. The authors do not expect lengthy conversations. Instead, we suggested targeted, respectful strategies in the ‘Discussion and directions for future research and practice’ section (including clinical practice frameworks, engagement with faith-based figures where appropriate, and reframing sex-positive aspects of religion) to mitigate ethnocentrism without overburdening HPs (See pp. 12–13).

To address the reviewer’s feedback, we have added the following sentence “It is not feasible to expect lengthy discussion on patients’ religious values to inform treatment. Rather, clinical practice frameworks with steps, precise wording, or phrases may help to address HPs’ reservations…” (See ‘Discussion and directions for future research and practice’ section, p. 12, lines 489–494). 

Comment 13: Issues raised in Lines 457-460 impacts all women irrespective of background.

Response 13: We appreciate the reviewer’s comments. We fully recognise that many gynaecological issues affect women across backgrounds. However, the study’s stated focus (outlined in the methodology) is on structures beyond patriarchy that may additionally marginalise women and other minorities.

To address the reviewer’s point explicitly, we have added the following sentence: “The authors recognise that sexism continues to pose significant barriers for the majority of women’s gynaecological healthcare irrespective of background; however, this study examines the implications of other often-overlooked structural factors.” (See ‘Theoretical frame’ subsection, p. 3, lines 110–113).

Comment 14: I would consider it a biological fact that women lose sexual desire as they get older because of reducing oestrogen. Ofcourse, there are women who still have a sex drive at an older age but nevertheless, it is not unreasonable for HP to work on the notion to the contrary – this is not ageism but working with averages/general trends in order to facilitate decision making. That there is a majority is not a value judgement against those that fall beyond that.

Response 14: We thank the reviewer for this biological clarification. We have added the following acknowledgment: “While it is acknowledged that women’s ageing correlates with decreased sexual desire due to reducing oestrogen levels, HPs should strive to avoid over-generalising this trend to all older women and apply case-by-case assessment of individual goals.” (See ‘Discussion and directions for future research and practice’ section, p. 13, lines 556–559).

This addition reinforces the manuscript’s original point: to highlight the risk of over-generalising reduced sexual desire to all older women while encouraging case-by-case assessment of individual goals. The section also retains the sentence “Conversely, aging and/or disabled people with vaginismus that clearly indicate that they do not desire sex should be respected and not disbelieved” to remain inclusive of those with reduced libido due to ageing (See ‘Discussion and directions for future research and practice’ section, p. 14, lines 588–590).

Comment 15: Limitations are the fact that the study actively seeks to interpret findings from a structural inequality context without considering alternative explanations.

Response 15: Thank you for this comment. The manuscript states its use of a CFPS framework in the ‘Methods’ section, so the structural-inequality lens is a deliberate analytical focus rather than an unacknowledged limitation. Alternative explanations, such as knowledge gaps are acknowledged where relevant in the discussion, but in-depth exploration of them falls outside this study’s scope

Comment 16: Ultimately – gynaecological healthcare is a problem for probably the majority of women irrespective of background. Many women are traumatised by repeated examinations and the approach of consultants in which the sexual organs are treated as if they are disconnected to a human being. The fundamental issue is sexism. The paper has utility in highlighting the needs of non-majority groups that absolutely should be addressed, but as a qualitative piece of research, there is no evidence for the assertions being made about various isms. The authors don’t really present any sort of solution either – this could be working groups of patients who can recommend approaches although this could again could be an example of othering.

Response 16: We appreciate and thank the reviewer’s recognition of the paper’s utility in highlighting needs of non-majority groups, as well as the broader role of sexism in gynaecological care. In response, we have added an explicit statement acknowledging sexism as a key structural factor (see Response 13).

As a qualitative study, the aim is not to provide definitive or validated solutions, but to explore health professionals’ perspectives as per this study’s research question and identify areas for further development. The ‘Discussion and directions for future research and practice’ section outlines potential directions for clinical frameworks, education, and future research informed by the study findings (including refined Table 2 and newly added Table 3).

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript addresses an important and underexplored issue: how health professionals consider patient diversity when assessing and managing vaginismus. The qualitative design and the use of semi-structured interviews with clinicians across multiple disciplines provide useful insights into current practices and assumptions in sexual healthcare. The paper also contributes to ongoing discussions about inclusivity and heteronormativity in healthcare contexts.

Overall, the manuscript is clearly written, and the qualitative methodology is appropriate for the research question. The paper is suitable for publication after minor revisions.

A few areas could be strengthened to improve clarity and scholarly contribution:

The discussion strongly foregrounds the CFPS framework and related concepts, including heteronormativity, ethnocentrism, chrononormativity, and abjection. While these perspectives are valuable, some interpretations appear to extend beyond what is directly supported by the interview data. It would strengthen the analysis to more clearly distinguish between findings emerging from participants’ accounts and the authors’ theoretical interpretation, and to anchor key theoretical claims more explicitly in the empirical material.

While the manuscript engages well with feminist and critical theory, the discussion could more fully engage with the broader clinical literature on vaginismus and genito-pelvic pain/penetration disorder (GPPPD). Situating the findings more clearly within existing clinical frameworks and multidisciplinary treatment approaches would strengthen the link between theoretical insights and clinical implications.

The methods section is generally clear but would benefit from slightly more detail on the analytic process. In particular, the authors could clarify how the coding structure led to the two final themes, whether reflexive analytic practices (e.g., memo writing) were used during analysis, and how disagreements between coders were resolved.

The analysis of diversity (e.g., sexuality, gender diversity, religion, ethnicity, age, disability) is insightful but somewhat uneven. Some dimensions receive greater analytical attention than others. The authors may wish to clarify whether this reflects the distribution of the interview data or an analytical decision.

The recommendations for clinical practice and healthcare education are promising but could be framed slightly more cautiously, given the qualitative sample size (n = 23). Presenting these implications as directions for further research and practice development would strengthen the conclusions.

The discussion could be slightly tightened to reduce repetition of theoretical terminology and maintain focus on the empirical findings.

Overall, this is a thoughtful and relevant contribution to the literature on sexual health and inclusive healthcare practice. With minor revisions to clarify the analytical framing and strengthen the connection between findings and theory, the manuscript will make a valuable addition to the field.

Author Response

Comment 1: This manuscript addresses an important and underexplored issue: how health professionals consider patient diversity when assessing and managing vaginismus. The qualitative design and the use of semi-structured interviews with clinicians across multiple disciplines provide useful insights into current practices and assumptions in sexual healthcare. The paper also contributes to ongoing discussions about inclusivity and heteronormativity in healthcare contexts.

Response 1: We greatly thank the reviewer for their positive feedback on the manuscript addressing an important and underexplored issue and providing useful insights for ongoing discussions about inclusivity and heteronormativity in healthcare contexts.

Comment 2: Overall, the manuscript is clearly written, and the qualitative methodology is appropriate for the research question. The paper is suitable for publication after minor revisions.

Response 2: Thank you to the reviewer for their comments on the manuscript being suitable for publication after minor revisions.

All references to page and line numbers below are based on the revised manuscript with track changes (not the clean version).

Comment 3: A few areas could be strengthened to improve clarity and scholarly contribution:

The discussion strongly foregrounds the CFPS framework and related concepts, including heteronormativity, ethnocentrism, chrononormativity, and abjection. While these perspectives are valuable, some interpretations appear to extend beyond what is directly supported by the interview data. It would strengthen the analysis to more clearly distinguish between findings emerging from participants’ accounts and the authors’ theoretical interpretation, and to anchor key theoretical claims more explicitly in the empirical material.

Response 3: We are thankful for the reviewer’s feedback and made revisions to more clearly distinguish between participants’ accounts and theoretical interpretation, and to anchor key claims in the empirical data. These revisions have been made throughout the ‘Discussion and directions for future research and practice’ section (See track changes of reordered and reworded sentences in paragraphs throughout pp. 10–14).

Comment 4:  the manuscript engages well with feminist and critical theory, the discussion could more fully engage with the broader clinical literature on vaginismus and genito-pelvic pain/penetration disorder (GPPPD). Situating the findings more clearly within existing clinical frameworks and multidisciplinary treatment approaches would strengthen the link between theoretical insights and clinical implications.

Response 4: We appreciate this feedback. To incorporate the reviewer’s feedback, we used track changes to more clearly situate findings within existing clinical frameworks and multidisciplinary treatment approaches to strengthen the link between theoretical insights and clinical implications (See ‘Discussion and directions for future research and practice’ section, pp. 10-14, lines 405–410, 412–414, 426–430, 457–463, 479–481; 581–585). Please see accompanying added in-text citation numbers located in the full reference list for (51-54), (56-58), (66), (73-75), (101), & (105, 106).

Comment 5: The methods section is generally clear but would benefit from slightly more detail on the analytic process. In particular, the authors could clarify how the coding structure led to the two final themes, whether reflexive analytic practices (e.g., memo writing) were used during analysis, and how disagreements between coders were resolved.

Response 5: We appreciate and accept the reviewer’s feedback in the methods section which we have now addressed by adding both:

1). Detail on the use of reflexive research memo informing the coding structure of the two final themes (See ‘Procedure’ subsection, p. 5, lines 172–174, 178–179  & ‘Data analysis’ subsection, p. 5, line 183); and

2). Information on how disagreements were resolved between coders (See ‘Data analysis’ subsection, p. 5, lines 193–195).

Comment 6: The analysis of diversity (e.g., sexuality, gender diversity, religion, ethnicity, age, disability) is insightful but some what uneven. Some dimensions receive greater analytical attention than others. The authors may wish to clarify whether this reflects the distribution of the interview data or an analytical decision.

Response 6: We accept the reviewer’s nuanced feedback here and have actioned it by clarifying the focus on some diversity dimensions over others in the following statement added to the ‘Data analysis subsection’ (See p. 5, lines 187–189)

“There was a larger focus on certain diversity dimensions in the analytic coding due to the distribution of the interview data and participants’ less detailed responses on other diversity dimensions.”

Also, we have now added a new Table 3 in the ‘Results’ section on pp. 6–7 that reports on the ‘Number of HPs reporting consultations with patients by diversity type’ with clear numerical reporting of this data to clarify the distribution of the interview data.

Comment 7: The recommendations for clinical practice and healthcare education are promising but could be framed slightly more cautiously, given the qualitative sample size (n = 23). Presenting these implications as directions for further research and practice development would strengthen the conclusions.

Response 7: Thank you for these constructive comments. We have actioned them by softening the wording of recommendations throughout the manuscript using track changes. More cautious phrasing (e.g., “may”, “might”, “could”, “potentially”) now frames the implications as exploratory directions for future research and practice development, consistent with the qualitative sample size (See ‘Abstract’ section, ‘Discussion and directions for future research and practice’ section, and ‘Conclusion’ section).

We have also added the following sentence for additional cautious framing: “Given the sample size, the presented findings can be interpreted as exploratory and offering directions for future research and practice development in line with acceptable qualitative practice” (See ‘Discussion and directions for future research and practice’ section, p. 10, lines 382–384).

The section heading has also been reworded to “Discussion and directions for future research and practice” (See p. 10, line 377).

Comment 8: The discussion could be slightly tightened to reduce repetition of theoretical terminology and maintain focus on the empirical findings.

Response 8: We appreciate this feedback. We have accepted it by using track changes to reduce repetition of theoretical terminology and reduced discussion of abject theory (See ‘Discussion and directions for future research and practice’, pp. 13–14) to maintain stronger focus on the empirical findings. Paragraphs have also been reworded and reordered to foreground participants’ accounts (see Response 3 above).

Comment 9: Overall, this is a thoughtful and relevant contribution to the literature on sexual health and inclusive healthcare practice. With minor revisions to clarify the analytical framing and strengthen the connection between findings and theory, the manuscript will make a valuable addition to the field.

Response 9: We greatly appreciate the reviewer’s positive assessment that the work makes a thoughtful and relevant contribution to the literature on sexual health and inclusive healthcare practice. We have revised the manuscript accordingly to address all points raised.

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript aims to explore health professionals’ perceptions and experiences of patient diversity in the context of the assessment and treatment of vaginismus. The study employs a qualitative methodology based on semi-structured interviews with 23 professionals from diverse clinical backgrounds, which are analyzed using inductive thematic analysis. The research is grounded in a Critical Feminist Poststructuralist (CFPS) framework, which foregrounds the role of social norms and power relations in shaping clinical practices.

A key strength of the manuscript lies in the consistent integration of the critical feminist framework throughout all sections of the paper. This framework is not confined to the theoretical background but is clearly reflected in the formulation of the research question, the methodological design, and the interpretation of the findings. The authors do not position themselves as neutral observers, but rather explicitly acknowledge their critical standpoint, thereby enhancing epistemological transparency and enabling a nuanced analysis of how norms such as heteronormativity and ethnocentricity shape clinical practice.

Another strength is the focus on patient diversity and the effort to operationalize this concept empirically. This is particularly evident in the structure of the interview guide, which includes an initial stage mapping participants’ exposure to diverse patient populations, followed by in-depth questions on its clinical implications. In addition, presenting participant quotations alongside their professional roles enriches the contextual understanding of the data.
However, the issue of diversity remains somewhat underdeveloped in empirical reporting. The manuscript does not provide a systematic account of the extent and types of diversity encountered by participants, nor does it clarify how many participants reported working with diverse patient groups and in which dimensions. The absence of this information limits the reader’s ability to assess the empirical basis of the findings and could itself constitute an important finding that remains unexplored.

Author Response

Comment 1: The manuscript aims to explore health professionals’ perceptions and experiences of patient diversity in the context of the assessment and treatment of vaginismus. The study employs a qualitative methodology based on semi-structured interviews with 23 professionals from diverse clinical backgrounds, which are analyzed using inductive thematic analysis. The research is grounded in a Critical Feminist Poststructuralist (CFPS) framework, which foregrounds the role of social norms and power relations in shaping clinical practices.

A key strength of the manuscript lies in the consistent integration of the critical feminist framework throughout all sections of the paper. This framework is not confined to the theoretical background but is clearly reflected in the formulation of the research question, the methodological design, and the interpretation of the findings. The authors do not position themselves as neutral observers, but rather explicitly acknowledge their critical standpoint, there by enhancing epistemological transparency and enabling a nuanced analysis of how norms such as heteronormativity and ethnocentricity shape clinical practice.

Response 1: We greatly thank the reviewer for their positive comments on the strength of our manuscript’s critical feminist theoretical framework and authors’ positioning for a nuanced analysis of how norms shape clinical practice.

Comment 2: Another strength is the focus on patient diversity and the effort to operationalize this concept empirically. This is particularly evident in the structure of the interview guide, which includes an initial stage mapping participants’ exposure to diverse patient populations, followed by in-depth questions on its clinical implications. In addition, presenting participant quotations alongside their professional roles enriches the contextual understanding of the data. However, the issue of diversity remains somewhat underdeveloped in empirical reporting. The manuscript does not provide a systematic account of the extent and types of diversity encountered by participants, nor does it clarify how many participants reported working with diverse patient groups and in which dimensions. The absence of this information limits the reader’s ability to assess the empirical basis of the findings and could itself constitute an important finding that remains unexplored.

Response 2: We appreciate the reviewer’s thoughtful comment on both the strength of the manuscript’s focus on patient diversity and feedback for clearer reporting of types of patient diversity encountered by participants. To action this reviewer’s feedback, we have now added a new Table 3 in the ‘Results’ section on pp. 6–7 to include ‘Number of HPs reporting consultations with patients by diversity type’ with clear numerical reporting of this data.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I feel that the authors have taken in good faith my review and have addressed the comments accordingly.