Dear Dr. Walsh-Buhi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Malith Kumarasinghe, MBBS MD

Academic Editor

PLOS ONE

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2. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files.

Additional Editor Comments:

Overall

Please define the age group of youth as there are few differences in definitions globally.

Does the national survey capture the socioeconomic status in the national survey? This could be a valuable covariate!

It is better to include overall and modern contraceptive prevalence among youth along with the results of tables 2 & 4 to have an overall idea!

Lines 40-42-Abstract; Conclusion- Please reword

Line-67- reference at completion of the sentence!

Lines 77-81- Please reword the sentence!

Lines 87-89- Purpose does not match with the title and the objective given in the abstract! Please consider using “youth”.

Line 102- Please explain the reason for exclusion of pregnant youth. Specially with questions like “define withdrawal use: 1) ever use, 2) at first sex, 3) past 12 months, and 4) 109 past 3 months.[24]”

Results

Table 1 one- Will it possible to compare the demographic with national US data?

Table 1- Education level could be better presented with breakdown of the youth group say 15-19 and above 19 which could reduce the misinterpretation of higher representation of 9th grade or less/ high school in study cohort.

Table 2 & 4- It is better if you could present the survey wave results (overall) for the four variables in graph format for better presentation! The 1st 4 rows of the table 2.

Lines 190-192- Discussion- It is important that you explore the reasons for comparatively higher prevalence in 3rd wave and subsequent drop in 4th wave. This is an important discussion point!

Lines199-205- What is the influence of social media/ online content in determining the contraceptive practice!

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: May 20, 2024

Review of manuscript PONE-D-24-14716 entitled "Prevalence and correlates of withdrawal as contraceptive method in a nationally representative sample of youth: A cross-sectional study". The manuscript examines the trend of withdrawal use (exclusively or in combination with other methods) and its relation with the receipt of sexual education. The results contribute to the literature. The following issues need to be addressed before it can be publishable.

- P 4, LL 66-67; 73-74: The authors discuss that withdrawal is less effective method, while the failure rate of "correct" and "consistent" use of withdrawal is 4%. The higher failure rate of withdrawal is referred to its "typical use" that is estimated to be 20% in the USA and more or less in other parts of world (suggest reading this paper https://doi.org/10.1038%2Fs41598-023-37398-1). The authors need to specify that they are talking about the failure rate of the typical use of withdrawal. Studies on withdrawal usually tend to undermine the importance of this method for women's health (no side effects) and its wide availability, and its role in fertility transition.

- P. 5, LL83-84: The literature shows that the internet is the main source of sexuality education rather parents and siblings.

- Introduction: the importance of studying the relationship between sexuality education and withdrawal use has not been well stated. As mentioned, withdrawal is not part of family planning and sexual formal education of health systems. So, studying its relationship with withdrawal use does not sound clear to me here. The review of literature on this topic is very limited and short in this manuscript.

- L. 105: "Primary Measures" is an unusual term used for "dependent variables). Please consider revising it to "outcome" or "dependent" variables.

- There is a lack of theoretical logic for selecting covariates. Except the measures of sexuality education, al demographic variables have been studied by past studies. They are not the determinants of withdrawal use. I would suggest reviewing a tick literature on the relationship between sexuality education, as the source of contraceptive knowledge, and contraceptive use, which makes a good background for studying this relationship.

- L. 135: Please specify the type of logistic regression used and the justification for its use.

- The findings in LL. 171-174 is one of the key results of this study that needs an explanation in Discussion section. Please make sure to expand the discussion of why the receipt of informal sexuality education related to other methods of birth control was associated with the greater risk of using withdrawal in LL 198-202. Can this be due to the fact that those receiving education on the side effects of modern birth control (especially pills) are more likely to use withdrawal with combination of condoms in order to avoid the side effects of Pills and other hormonal methods?

- L 194: Revise " One potential reason for reason for".

Reviewer #2: Overall comment:

Thank you for the opportunity to review this manuscript. I appreciate the authors' efforts in conducting this study which explores an important area.The manuscript shows promise but requires further development. The research question is interesting, but the discussion could be strengthened. Minor revisions are recommended. Please see specific comments below.

Abstract

Results:

•The author mentions the prevalence of withdrawal is higher in combination than alone (lines 34-35). I would suggest adding “across all waves and reference period” and accompanying it with values to improve clarity.

•Suggest to report values for outputs from the regression model; AOR with CI

Conclusion:

broad and ambiguous. It could be precise and specific.

Main Manuscript

Methods:

Line 127- formal sexual education: it would be useful to mention the various sources similar to the types of informal sources mentioned.

Results:

•Line 166 refers to Table 3, it should be Table 4

•Table 4: Prevalence of non-Hispanic other population under ever use is reported incorrectly

Discussion:

•The findings of this study are based on contraceptive use that dates back to 5 years ago. The pattern of contraceptive use likely changed since the data collection for this study. If the finding were to be relevant even today to draw meaningful conclusions based on which policy decisions are made, it would be useful to compare patterns of contraceptive use from recent literature in the absence of updated prevalence rates of withdrawal in particular. This could strengthen the findings of the current study although not updated.

•A great many important covariates that have a direct influence on contraceptive use have not been explored in the study which is a major limitation and requires mentioning. Ex: previous experience, marital status, women's concerns on side effects preventing them from accessing other birth control methods, male partners' influence on deciding, power dynamics within relationships, educational level of the partner, cultural norms, economic status and cost of health insurance cover, sexual behaviour etc. However, given that the study was based on secondary data which would have failed to capture crucial factors, it would be useful to discuss the potential influence of these factors on the findings.

•Prevalence alone or in combination with other methods increased from 2011 to 2017 and then declined across all reference periods except for the 2013-2015 wave at first sex (Table 2). This trend observed needs an explanation.

•Line 199-202: The authors' explanation for higher odds of withdrawal used in combination with other methods is ambiguous. A possible explanation would be a sense of safety perceived when combined with other more effective methods. It still fails to explain the continuation of withdrawal despite being better informed.

•Line 211 needs a reference for this claim.

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Reviewer #1: No

Reviewer #2: No

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Dear Dr. Walsh-Buhi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 01 2025 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.

• 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'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Malith Kumarasinghe, MBBS MD

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.

Additional Editor Comments:

Dear Authors,

Please carefully address the comments and concerns of the reviewers.

Thank you

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: (No Response)

Reviewer #3: (No Response)

Reviewer #4: (No Response)

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #2: The authors have addressed most of the comments adequately. However, the following still needs to be addressed:

1.Abstract- results- although prevalence has been reported, it is best reported accompanied with Confidence intervals. (Interval estimates).

2.The original comment “Methods: Line 127- formal sexual education: it would be useful to mention the various sources similar to the types of informal sources mentioned”. - not addressed, although the authors say they have! Line 157-159 in the revised manuscript.

Reviewer #3: Reviewer comments

Thank you for the opportunity to review this revised manuscript – PONE-D-24-14716_R1. Most of the editor comments and two reviewers’ comments were addressed. Recommend to publish with the following minor revisions.

1. Defining the age group of youth should be clearer and should be unique throughout the manuscript.

2. In the line 66 – put the reference at the completion of the sentence.

3. Lines 88 – 90 consider using “youth” still not addressed properly.

Reviewer #4: This was an interesting article researching a currently relevant topic. Congratulations on a job well done!

I have three concerns, as all others have been addressed by previous reviewers.

My first concern is in the discussion section line 213-216, where you describe "the increase of withdrawal use during the 2015-2017 wave may be partially explained by the beginning of the Donald Trump administration which heavily defunded comprehensive sexual health programs between 2016 and 2020".

- the timing for the explanation does not line up as the change happens before the administration comes in to power. Therefore, your concusion loses it's validity.

My second cencern is the clain that this is an "update". line 195-197. "The goal of the current study was to provide an update of the prevalence of withdrawal as a contraceptive method in a nationally representative sample of American youth as well as to examine the relationship between informal sexuality education and withdrawal".

- as the most recent data is from 2019, you may need to clarify regarding the availability of the data. That is, the most recent available NSFG data is from ........

My third concern is that the persons delivering formal sexual education have not been specified or identified. That is, the receipt/ acceptance of sexual education may differ on the expertise/ perceived reliability of the individual delivering it. Thus it would be great to have it addressed in the writing.

Thank you.

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Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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Attachments

Attachment

Submitted filename: Reviewer commnets for the revised manuscript.docx

The Role of Sex Education in Withdrawal Use: Prevalence and Correlates Among a Nationally Representative Sample of Adolescents and Young Adults

PONE-D-24-14716R2

Dear Dr. Walsh-Buhi,

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.

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Jianhong Zhou

Staff Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

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

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

Reviewer #2: I am happy to note that the authors have attempted to address all concerns. However, I would like to stress that while standard error can be used to describe the uncertainty in a prevalence estimate, confidence intervals are generally preferred because they provide a more informative and easily interpretable measure of the precision of the estimate.

In light of lack of data to compute confidence intervals I suppose it is acceptable to use standard error values.

I recommned the acceptance of the manuscript in its current form.

**********

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Reviewer #2: No

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