Abstract
Dear Editor:
My co-authors and I would like to respond to a letter by Drs. Alexander and Courtois recently published in the Journal of Neurotrauma (DOI: 10.1089/neu.2016.4810) commenting on our December 2016 review entitled, “Cardiovascular Responses to Sexual Activity in Able-Bodied Individuals and Those Living with Spinal Cord Injury.” 1
We thank the commenting authors in supporting our assertion that this is a controversial topic. With this letter, we would like clarify any confusion that readers may have experienced while reading our review. In no way did we aim to discourage the expression of sexuality after spinal cord injury (SCI). The aim of our article was to review the available literature on the cardiovascular responses during sexual stimulation, whether it is self, partner, or vibrostimulation (commonly used by men and women with SCI at home or for men during sperm retrieval).
Drs. Alexander and Courtois write that we have omitted significant published data in this review, to which we respond that only articles that had clear reported cardiovascular data were included. Many articles without clear cardiovascular monitoring protocols were excluded, including some of their own studies, as well as studies of those of some of the authors (A.K. and S.L.). If there are crucial publications that we missed based on our inclusion/exclusion criteria, we would be pleased to review them.
It was stated that we did not take into account the number of subjects in the published articles referenced. The number of subjects is clearly indicated in the tables for all to read. If the data in this section were meta-analyzed, then it could lead to overestimation of the estimated rise in blood pressures (BPs), but we made no such calculation for individuals living with SCI in the article.
It was stated that we primarily reported data regarding vibratory stimulation. Tables 1 and 2 describe the method of stimulation in the left-hand column, and text in the review is stratified first by able-bodied versus individuals living with SCI, and then by stimulation type. For people living with SCI, there were nine studies that describe laboratory-based vibratory stimulation as the activity and nine studies that describe other forms of sexual activity. It is pointed out that references 41, 42, and 43 draw from the same group of participants and, perhaps, the same trials. This is an astute observation, and we apologize for any confusion; however, taking out any two of those studies still leaves ample data from which to draw conclusions about a variety of stimulation types. If any two of the three studies were removed, it would make no difference to the conclusions made in the article, given that we did not meta-analyze the data for the SCI participants.
It is unfortunate that our colleagues believe that BP data achieved by continuous monitoring is overestimated given that it was obtained by more-precise technology than older hand-held BP cuffs, especially when the BP achieved, in some studies, was often triple or quadruple the cutoff for autonomic dysreflexia (AD). The fact that some laboratories are capable of detecting BP more accurately does not indicate that they should be obviated from analysis, but held to a higher regard given the possible consequences of BP in this range. 2,3 Given that symptoms of AD do not correlate with the amount of increase in BP, 4 clinicians must rely on measurement to determine the risk of hypertensive complications and the need for prophylactic treatment or not.
The primary importance of this review is clinical awareness of true values and what that may mean for the safety of persons with SCI, not to promote fear of, or discourage, sexual activity. Table 3 illustrates for readers that hand-held or automated devices at 1-min, or every 3 min, intervals often miss the peak BP achieved at ejaculation for men with SCI. This holds even when removing two of the three duplicated studies.
Denying that these BP values exist or are exaggerated impedes science and may lead to false reassurance for patients. The ultimate health risk to patients experiencing AD during sexual practices has not been determined, so, as clinicians, we feel that it is our responsibility to encourage sexual activity with precautions, especially in those at highest risk for AD.