Physiological Parameters Associated With Psychogenic Sexual Arousal in Women With Complete Spinal Cord Injuries

Transcription

1 811 Physiological Parameters Associated With Psychogenic Sexual Arousal in Women With Complete Spinal Cord Injuries Marca L. Sipski, MD, Craig J. Alexander, PhD, Raymond C. Rosen, PhD ABSTRACT. Sipski ML, Alexander C J, Rosen RC. Physiological parameters associated with psychogenic sexual arousal in women with complete spinal cord injuries. Arch Phys Med Rehabil 1995;76: Objective: To compare the physiological sexual responses of women with complete spinal cord injuries (SCIs) with those of able-bodied women. Design: Controlled laboratory-based analysis of responses to audiovisual erotic and audiovisual erotic combined with manual stimulation. Setting: The sexual physiology laboratory at our freestanding rehabilitation hospital. Participants: A volunteer sample of 13 women with complete SCIs above T6 along with eight able-bodied women, matched for age and educational status. Interventions: A 78-minute protocol using 6-minute baseline alternating with 12-minute testing conditions was conducted. Dependent variables: Included vaginal pulse amplitude, subjective arousal, heart rate, blood pressure, and respiratory rate. Results: Showed comparable increases in subjective arousal in both groups with audiovisual but not audiovisual combined with manual stimulation. Vaginal pulse amplitude increased in able-bodied subjects but no SCI subjects with isolated audiovisual stimulation; however, with the addition of manual stimulation all subjects responded similarly. Other nongenital correlates of sexual arousal were similar between SCI and able-bodied subjects. Conclusion: These results provide physiological validation of the hypothesis that women with complete SCI can respond with audiovisual stimulation similarly to able-bodied women in those functions that are controlled neurologically above the level of their injuries, whereas, genital vasocongestion will not occur because the neurological pathway is interrupted. In contrast, reflex genital vasocongestion can occur in women with complete SCI despite a lack of subjective arousal. These findings can be used to educate women with complete SCIs about their sexual responses by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation Sexuality is an important aspect of a person's life. When an individual sustains a spinal cord injury (SCI) there is an immediate impact on the emotional and physical aspects of their sexuality. SCI affects approximately 177,000 Americans, 20% of whom are women.l'2 Despite the obvious effects of SCI on sexual function and the large population that suffers from this injury, little is known about the impact of SCI on the physiology of female sexual arousal. It has been hypothesized that female sexual function should be altered in a similar fashion to male function after SCI. 35 Research has suggested that some women with SCIs complain of inadequate vaginal lubrication. 6 Furthermore, recently published data 6'7 indicate that approximately 50% of women with SCI report an inability to achieve orgasm. Only one questionnaire study to date has attempted to determine the impact of different degrees of SCI on vaginal lubrication] In this report, 25 women of known neurological status were queried about their ability to achieve psychogenic, reflexive, and combined lubrication. Findings suggest that the self-report method is inadequate as many From the Kessler Ins~Litute for Rehabilitation (Drs. Sipski, Alexander), West Orange, NJ; Northern New Jersey Spinal Cord Injury System, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ; and the Robert Wood Johnson Medical School (Dr. Rosen), University of Medicine and Dentistry of New Jersey, Piscataway, NJ. Submitted for publication March 6, Accepted in revised form April 23, Supported by grant HD from the National Institutes of Health. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Address reprint requests to Marca L. Sipski, MD, Kessler Institute for Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ by the American Congress of Rehabilitation Medicine and the American Academy of Physical ldedicine and Rehabilitation /95/ /0 subjects were unaware of their ability to lubricate. Moreover, these women were unable to distinguish between varying types of lubrication, and this method is insufficient to obtain objective, quantitative data on sexual arousal. In this study, our goal was to assess and quantify the effects of various types of stimulation on female sexual response in women with complete SCI at the level of T6 and above, as compared with able-bodied women. The impact of audiovisual erotic stimulation and audiovisual combined with manual stimulation on subjective sexual arousal, vaginal blood flow, heart rate, blood pressure, and respiratory rate was studied. We hypothesized that women with complete SCI at the level of T6 and above would not exhibit increased vaginal blood flow in response to erotic audiovisual stimulation alone, but would show increased vaginal blood flow in response to combined erotic audiovisual and manual stimulation. This hypothesis is based on the assumption that women with complete SCI are able to maintain reflexive, but not psychogenic vaginal vasocongestion. 3-5 In contrast, we anticipated that able-bodied subjects would respond with increased vaginal blood flow to erotic audiovisual stimulation, and that this would be augmented by the addition of manual stimulation. It was also predicted that other measures of arousal such as heart rate and respiratory rate would be altered similarly to those of able-bodied subjects; whereas, the blood pressure responses of SCI subjects during manual stimulation would be higher than those of able-bodied subjects. This was anticipated because SCI subjects are susceptible to autonomic dysreflexia during sexual activity, and we have previously observed extreme blood pressure elevations during laboratory studies of an SCI woman who stimulated herself to orgasm)

2 812 PSYCHOGENIC SEXUAL AROUSAL IN WOMEN WITH SCl, Sipski METHODS Subjects Subjects were solicited nationally via advertisements in magazines appealing to individuals with SCI, in addition to advertisements in local newsletters and bulletin boards. Subjects were eligible for participation only if they had regular menstrual cycles, had not had gynecological or neurological surgery, were free from psychiatric disorders and were medically stable. Subjects included 13 women with American Spinal Injury Association 9 (ASIA) class A tetraplegia, in addition to eight able-bodied control subjects. Of the subjects with SCI, two had insufficient upper extremity function to perform any self-stimulation; however, they met all other inclusion criteria and were willing to participate. Therefore, they were included in those aspects of the study where isolated and audiovisual stimulation were used and omitted from parts of the study requiring manual stimulation. Women with SCI were a mean of 94 months postinjury with a range of 12 to 232 months. Levels of injuries ranged from C2 to T5 with precise levels listed in the table. Mean age for SCI subjects was 30 years (25 to 44) and mean age for able-bodied subjects was 36 years (24 to 49). Mean years of education for SCI subjects was 14 years, whereas that of able-bodied subjects was years. Marital status of SCI subjects included seven single subjects, two married, one separated, and one divorced, whereas that of able-bodied subjects included three single subjects, three divorced, and two married (table). Procedure This study represented day one of a 3-day study designed to investigate all aspects of the sexual response cycle. Day two and day three of the study were designed to examine the impact of SCI on orgasm and reflex vaginal lubrication. These data will be presented elsewhere. The project was approved by the Institutional Review Board at Kessler Institute and full informed consent was obtained from all subjects before participation. All subjects required clearance from their gynecologist and verification of the absence of gynecologic problems before study participation. Subjects were also required to monitor their menstrual cycles for a minimum of 2 months before study participation so that all testing could be performed between days 16 and 21 of the menstrual cycle. After study completion subjects were reimbursed $400 for their participation. Prestudy Testing Subjects underwent a comprehensive medical examination and neurological assessment according to the International Standards for Classification of Spinal Cord Injury as published by ASIA. 9 This testing was performed by the principal investigator. Furthermore, all subjects underwent anal sphincter electromyography and somatosensory evoked potential testing by a single examiner using a Dantec Counterpoint device (no. 9018A004P). Subjects were verbally administered a questionnaire developed by the investigators designed to specifically assess the impact of SCI on their physiological sexual functioning. Equipment For the experimental session, subjects were brought into a private, wheelchair-accessible laboratory room and asked to rest on a hospital bed. Subjects donned hospital gowns and the physiological electrodes were attached by a trained, female research assistant. These included a PPS photoelectric pulse sensor b placed on the right big toe to measure heart rate, nasal/oral thermocouple transducers (model no. Subject Characteristics ASIA Age Level of Injury ASIA Motor Score Sensory Score Etiology Months Post Injury Marital Status Years of Education 29 T PIN/50-LT MVA 72 Single C PIN/25-LT GSW 62 Single C PIN/15-LT GSW 29 Single 9 22 T PIN/38-LT Diving 60 Single C4 -C PIN/16-LT MVA 224 Married T PIN/42-LT MVA 242 Divorced C6 - C PIN/28-LT Diving 113 Married T PIN/42-LT GSW 12 Separated C PIN/31 -LT Diving 116 Single C PIN/22-LT Boating 47 Married C PIN/29-LT Diving 18 Single C PIN/14-LT MVA 75 Single C PIN/11 -LT MVA 176 Single No Injury Normal Normal None None Divorced No Injury Normal Normal None None Single No Injury Normal Normal None None Divorced No Injury Normal Normal None None Married No Injury Normal Normal None None Single No Injury Normal Normal None None Married No Injury Normal Normal None None Divorced No Injury Normal Normal None None Single 17 Abbreviations: MVA, motor vehicle accident; GSW, gunshot wound. Arch Phys Med Rehabil Vo! 76, September 1995

3 PSYCHOGENIC SEXUAL AROUSAL IN WOMEN WITH SCI, Sipski 813 ONT2 b) to measure nasal respirations, and a one-fourth inch vaginal photoplethysmograph c with stereo pack set in the AC mode to measure vaginal pulse amplitude. All sensors were connected to a Grass Model 7G polygraph b and an analog to digital convertor (model no. D1601 d) was used to transfer the data to a 486 DX33 personal computer, e Matlab high performance numeric computation software ~ was used to analyze and plot all physiological data. A Criticare noninvasive patient monitor model (no. 508 g) was used to monitor blood pressure via a Criticare calibrated V-lok cuff g located on the nondominant arm. Study Protocol Subjects underwent a 78-minute study protocol designed to examine their responses to erotic audiovisual and erotic audiovisual combined with manual stimulation of their clitoral region. At the beginning of the protocol and at 3-minute intervals througihout subjects were asked, via intercom, to report their subjective level of arousal on a scale of zero to 10. Zero represented no arousal with 10 representing maximum subjective arousal. The 78-minute protocol was divided up as follows: asl initial 6-minute baseline period (B1), 12 minutes of audiovisual stimulation (V1), 6 minutes of baseline (B2), 12 nfinutes of audiovisual stimulation (V2), 6 minutes of baseline (B3), 12 minutes of audiovisual combined with manual stimulation (VM1), 6 minutes of baseline (B4), 12 minute,; of audiovisual combined with manual stimulation (VM2) ~md 6 final minutes of baseline (B5). For the two sessions of audiovisual combined with manual stimulation, the subjects were told to discontinue clitoral stimulation for two 45-second intervals: from 6 minutes to 6 minutes and 45 seconds into the protocol, and from 11 ]minutes and 15 seconds to 12 minutes into the protocol. These rest periods were included to assess the effects of manual stimulation in the absence of potential movement artifact (fig 1). Continuous physiological data were acquired via the sensors and the polygraph. Using Matlab software, data sampiing was performed at 10-second intervals for heart rate and vaginal pulse amplitude, and at 1-minute intervals for respiratory rate. Heart rate, respiratory rate, and vaginal pulse amplitude data were then converted to a digital format and median readings were obtained for each experimental session. For vaginal pulse amplitude, during the manual and audiovisual stimulation phases, the median readings were obtained for the 45-second rest periods, in addition to the active stimulation periods. Blood pressure and subjective arousal level data were obtained at 3-minute intervals throughout the protocol and recorded in the computerized data base. Analysis Appropriate descriptive statistics were used to characterize study participants in each of the study groups. Differences were examined both within and between subject groups. Within subject group differences were determined using matched pair t tests between means of similar treatment conditions. Between subject group differences were determined using analyses of variance (ANOVA). Treatment phase differences between subject groups were determined using ANOVA procedures on various change scores described in the results section. All statistical analyses were conducted using SPSS release 6.6. h An alpha level of.05 was set as the acceptable level of significance for these data. Vaginal Vasocongestion RESULTS Vaginal pulse amplitude (VPA) readings were compared within subject groups to determine whether a significant difference could be detected between baselines one through five, in the experimental protocol (fig 2). Matched pair t- tests showed a significant difference between baseline conditions for the able-bodied subjects. Baselines two through five were all significantly greater than the initial baseline (p <.05) with means indicating an increasing cumulative excitation effect (B1 M = 6.97, B2 M = 9.54, B3 M = 10.15, B4 M = 10.40, B5 M = 10.94). There was no significant difference in baselines for women with complete spinal injuries. Between group differences showed that able-bodied subjects had a significantly greater mean baseline VPA (M = 9.60) than complete SCI subjects (M = 5.02) F(1, 17) = 5.19, p =.03. The effect of audiovisual stimulation alone on VPA was assessed by comparing the mean of visual 1 and visual 2 with the mean of baselines 1 and 2. For the able-bodied subjects paired t-test showed a significant increase in VPA in response to audiovisual stimulation (M = 10.67) over baseline condition (M = 8.26) t(7) = 2.80, p =.03. However, there was no significant difference in these same conditions for the complete SCI subjects (t(12) = -1.58, p >.05). Fig 1--Vaginal pulse amplitude without movement artifact (left side) and with movement artifact (right side).

4 814 PSYCHOGENIC SEXUAL AROUSAL IN WOMEN WITH SCl, Sipski MERN VRG I NR L PU LSE RMP L I TUDE i i i / / //" ",,,,,,, / "-, /"',.,, v..f...o j ''''"... /'/ -.; i J i i BI Vl B2 V2 B3 VM] B4 VM2 B5 TREflTMENT CON]] l T 1 ON Fig 2--Mean vaginal pulse amplitude, patients with complete injuries ( ) vs able-bodied (- - -). Vaginal pulse amplitude change scores with audiovisual stimulation were evaluated between subject groups using the following formula: (visual 1 + visual 2) - (baseline 1 + baseline 2)/(baseline 1 + baseline 2) x 100. Able-bodied subjects evidenced a significantly greater VPA change score (M = 24.15) than the complete SCI subjects (M = 7.62), F(1, 19) = 5.65, p =.03. The response to audiovisual combined with manual stimulation was compared with the response to audiovisual stimulation alone along with responses during baselines 3 and 4. Within subject groups the mean of conditions visual plus manual stimulation 1 and 2 were compared with the mean of the audiovisual stimulation conditions 1 and 2. For ablebodied subjects paired t-test showed a significant greater VPA with visual plus manual stimulation (M = 12.72) as compared with audiovisual alone (M = 10.67) t(7) = 3.31, p =.01. These same conditions, however, were not significantly different for the complete SCI subjects, t(10) = 1.64, p >.05. The effect of visual plus manual stimulation, versus audiovisual stimulation alone was assessed between subject groups by comparing differences on the following change score formula: (visual plus manual 1 + visual plus manual 2) - (visual 1 + visual 2)/(visual 1 + visual 2) x 100. ANOVA on this measure showed no significant difference between able-bodied subjects and complete SCI subjects, F(1, 17) =.05, p >.05. The effect of audiovisual plus manual stimulation versus baseline conditions was assessed between subject groups using the following change score formula: (visual plus manual 1 + visual plus manual 2) - (baseline 3 + baseline 4)/(baseline 3 + baseline 4) x 100. Results showed no significant difference between able-bodied subjects and complete SCI subjects on this measure, F(1, 17) =.91, p >.05. In summary, vaginal pulse amplitude results indicated that women with complete SCIs did not show vaginal vasocongestion in response to pure psychogenic sexual stimulation, whereas able-bodied subjects did. In contrast when manual stimulation was added similar increases in vaginal pulse amplitude were observed in both complete SCI subjects and able-bodied controls. Subjective Arousal Figure 3 depicts variations in subjective arousal levels during the experimental phases. Arousal ratings were compared between groups to determine if there was a significant difference between mean baseline (B 1 + B2 + B3 + B4 + B5)/5 arousal levels. Able-bodied subjects showed significantly greater combined baseline arousal levels (M = 2.25) than complete SCI subjects (M =.64) F(1,17) = 4.79, p =.04. Arousal levels during audiovisual stimulation (V1 + V2)/2 were not significantly different between able-bodied and SCI subjects F(1,19) = 2.64, p >.05. However, subjective arousal levels during audiovisual combined with manual stimulation (VM1 + VM2)/2 were significantly different between able-bodied (M = 6.0) and complete SCI subjects (M = 3.5) F(1, 17) = 4.75, p =.04. Responses to audiovisual stimulation versus baseline arousal level readings were compared both within and between groups. Within groups the mean of visual 1 and visual 2 was compared with the mean of baseline 1 and baseline 2. In able-bodied subjects paired t-test showed a significant increase in arousal level to audiovisual stimulation (M ) over baseline stimulation (M = 2.12), t(7) = 3.95, p =.006. For complete SCI subjects there was also a significant increase in arousal level with audiovisual stimulation (M ) versus baseline (M =.71) t(12) = 5.08, p <.001. Between group differences were compared using the change score formula (visual 1 + visual 2) - (baseline 1 + baseline 2)/(baseline 1 + baseline 2) x 100. There was not a significant difference in the arousal level response to audiovisual stimulation versus baseline between groups F(1, 19) = 2.64, p >.05. Responses to audiovisual combined with manual stimulation were compared both within and between groups. For able-bodied subjects there was a significant increase in arousal level with audiovisual combined with manual stimulation (M = 6.0) versus baseline (M = 4.5) t(7) = -3.38, MERN RROUSRL LEVEL / v J L Bi Vl B2 V2 B3 VMI B4 VM2 B5 TRERTMENT COND l T I ON Fig 3--Mean subjective arousal levels, 0 through 10, for patients with complete injuries (- - -) vs able-bodied ( ).

5 PSYCHOGENIC SEXUAL AROUSAL IN WOMEN WITH SCI, Sipski 815 p =.01. In complete SCI subjects, however, there was not a significant change in arousal levels between these treatment conditions t(10) = -2.06, p =.07. Between group differences were compared using the change score formula (visual plus manual 1 + visual plus manual 2) - (visual 1 + visual 2)/(visual 1 + visual 2) x 100. Analysis of variance on this measure was significantly different between able-bodied and complete SCI subjects F(1, 17) = 4.75, p =.04. In summary, subjective arousal levels during pure psychogenic sexual stimulation were,, similar between able-bodied controls and SCI subjects; whereas, with the addition of manual stimulation the subjective arousal of able-bodied controls but not subjects with complete SCI showed a further increase. Cardiovascular Response Heart rate responses throughout the treatment sessions are depicted in figure 4. Between group differences showed that there was no significant difference in mean baseline heart rates between groups F(1, 16) = 1.49, p >.05. There was also no significant difference in heart rates between groups during audiovisual stimulation (V1 + V2) F(I, 19) = 2.699, p >.05, or during audiovisual combined with manual stimulation (VM1 + VM2) F(1, 17) =.672, p >.05. The effect of isolated erotic audiovisual stimulation on heart rate within groups was assessed by comparing the mean of visual 1 and visual 2 with the mean of baselines 1 and 2. For the able-bodied subjects paired t-test showed a significant increase in heart rate in response to audiovisual stimulation (M = 78.75) over baseline control (M = 76.25) t(7) = 3.57, p <.01. For the complete SCI subjects there was also a significant increase in heart rate with audiovisual stimulation (M = 86.24) over baseline control (M = 84.38) t(12) = 2.39, p =.03. Between group differences were also evaluated using the following formula: (visual 1 + visual 2) - (baseline 1 + baseline 2)/(baseline 1 + baseline 2) x 100. Analysis of variance on this measure was not significant between able-bodied and complete SCI subjects, F(1, 19) =.577, p >.05. MEAN HEART RATE i B1 VI B2 V2 B3 VM1 B4 VM2 B5 TREATMENT CONDITION Fig 4--Mean heart rate, patients with complete injuries (- ) vs able-bodied (- - -). MEflN SYSTOLIC BLOOD PRESSURE 150 lqo iso 120 ii0 i00 B1 Vl B2 V2 B3 VM1 B4 VM2 B5 TREATMENT CON]] I T I ON Fig 5--Mean systolic blood pressure, patients with complete injuries ( ) vs able-bodied (- - -). The effect of audiovisual combined with manual stimulation was compared with audiovisual stimulation alone on heart rate both within subject groups and across subject groups. Within subject groups the mean of conditions visual plus manual stimulation 1 and 2 were compared with the mean of the audiovisual stimulation conditions 1 and 2. For able-bodied subjects paired t-test did not show a significant difference t(7) =.88, p >.05. This result was also not significant for subjects with complete SCI t(10) =.20, p >.05. Between group differences were also evaluated using the following change score formula: (visual plus manual 1 + visual plus manual 2) - (visual t + visual 2)/(visual 1 + visual 2) x 100. ANOVA on this measure was not significant between able-bodied subjects and complete SCI subjects F(1, 17) =.893, p >.05. Taken as a whole, the heart rate responses of able-bodied and SCI subjects were similar during all experimental conditions. Responses for systolic blood pressure (SBP) are shown in figure 5. Between group analysis indicated that there was no significant difference in mean baseline SBP levels F(1, 17) ,p >.05. There was also no significant difference in responses during audiovisual stimulation alone (V1 + V2) F(1, 18) =.29, p >.05 or audiovisual combined with manual stimulation (VM1 + VM2) F(1, 17) =.0008, p >.05. The effect of audiovisual stimulation alone compared with baseline readings on SBP was compared within and between groups. Within groups the mean of visual 1 and visual 2 was compared with the mean of baselines 1 and 2. For the able-bodied subjects paired t-test showed a significant increase in SBP in response to audiovisual stimulation (M = ) over baseline conditions (M = ) t(7) = -2.35, p However, there was no significant difference in SBP during these same conditions for the complete SCI subjects t(12) = -1.09, p >.05. The effect of audiovisual stimulation versus baseline was evaluated between subject groups using the following change score formula: (visual 1 + visual 2) - (baseline 1 + baseline 2)/(baseline 1 + baseline 2) X 100. ANOVA on this measure was not significant

6 816 PSYCHOGENIC SEXUAL AROUSAL IN WOMEN WITH SCl, Sipski between able-bodied subjects and complete SCI subjects, F(1, 19) =.205, p >.05. The effect of audiovisual stimulation combined with manual stimulation on SBP compared with changes during audiovisual stimulation alone were similarly compared within and between groups. In able-bodied subjects SBP during audiovisual combined with manual stimulation (VM1 + VM2) was significantly higher (M = ) than during audiovisual stimulation alone (V1 + V2) (M = ) t(7) = 6.69, p <.001. For subjects with complete SCI, SBP was also significantly higher during audiovisual combined with manual stimulation (M = ) compared with audiovisual stimulation alone (M = ) t(10) = 2.33, p =.04. Between subject groups, the effect on SBP of audiovisual stimulation combined with manual stimulation versus audiovisual stimulation alone was assessed by comparing differences on the following change score formula: (visual plus manual 1 + visual plus manual 2) - (visual 1 + visual 2)/(visual 1 + visual 2) x 100. ANOVA on this measure was not significant between able-bodied subjects and complete SCI subjects, F(1, 17) =.52, p >.05. In summary, the responses of subjects with SCI and able-bodied controls were generally similar with regards to SBP. Respiration Responses for respiratory rate are shown in figure 6. There was a significant difference in mean baseline readings between able-bodied subjects (M = 19.13) and complete SCI subjects (M = 15.05) F(1, 17) = 14.39, p =.001. Ablebodied subjects had a significantly higher respiratory rate (M = 18.19) than did complete SCI subjects (M = 14.54) during audiovisual stimulation alone (V1 + V2) F(1, 19) = 5.59, p =.03 and during audiovisual combined with manual stimulation (VM 1 + VM2) F(1, 17) = 11.31, p =.004 (ablebodied M = 20.06; SCI M = 16.23). The effect of audiovisual stimulation alone on respiratory rate was compared within groups. This effect was assessed by comparing the mean of visual 1 and visual 2 with the 24 MERN RESPIRRTION RRTE , _ m i B1 Vl B2 V2 B3 VM1 B4 VM2 B5 TRERTMENT COND I T I ON Fig 6--Mean respiration rate, patients with complete injuries ( ) vs able-bodled (- - -). mean of baselines 1 and 2. For the able-bodied subjects there was not a significant difference with audiovisual stimulation over baseline control t(7) =.36, p >.05. For those subjects with complete SCI there was also not a significant difference t(12) =.27, p >.05. Between subject groups, the effect of respiratory rate of isolated audiovisual stimulation compared with baseline was computed using the following change score formula: (visual l + visual 2) - (baseline 1 + baseline 2)/(baseline 1 + baseline 2) X 100. ANOVA on this measure did not show any significant difference between subjects with complete SCI and able-bodied subjects F(1, 19) =.11, p >.05). The effect of audiovisual combined with manual stimulation (VM1 + VM2) was compared with baseline readings (B3 + B4) within groups. There was no significant difference in this measure for able-bodied subjects t(7) =.36, p >.05 or subjects with complete SCI t(10) = 1.61, p >.05. The effect of audiovisual combined with manual stimulation (VM1 + VM2) was also compared with audiovisual stimulation (V1 + V2) within groups. There was a significant increase in respiratory rate with audiovisual combined with manual stimulation for SCI subjects (M = 16.23) as compared with audiovisual stimulation alone (M = 14.05) t(10) = -2.95, p =.01. However, able-bodied subjects did not show a significant difference on these same two measures (p >.05). The effect of audiovisual combined with manual stimulation versus audiovisual stimulation alone on respiratory rate between subject groups was assessed using the following change score formula: (visual plus manual 1 + visual plus manual 2) - (visual 1 + visual 2)/(visual 1 + visual 2) 100. ANOVA on this measure did not show any significant difference between groups F(1, 17) =. 18, p >.05. In summary, the pattern of respiratory responses was generally similar between complete SCI subjects and ablebodied subjects. DISCUSSION This report describes the first laboratory-based, controlled study of sexual function in women with SCI. The methodology developed was found to be effective in eliciting isolated psychogenic sexual arousal through the viewing of explicit, erotic videotapes and in eliciting a combined psychogenic/ reflexogenic sexual arousal through the viewing of explicit, erotic videotapes along with performance of manual selfstimulation to the clitoral region. Furthermore, in this setting we were able to evaluate both able-bodied control subjects and those with high levels of SCI. Perhaps the first important question in this research is the degree to which the women were able to be aroused in the laboratory setting. Results indicated that subjective arousal did, in fact, occur and that both able-bodied subjects and subjects with complete SCI were psychogenically sexually aroused with isolated audiovisual sexual stimulation. When manual clitoral stimulation was added to the audiovisual stimulation to provide the condition of psychogenic/reflexogenic sexual stimulation, able-bodied subjects showed significantly greater subjective arousal levels than subjects with complete SCI. This result is consistent with the hypothesis that subjects with complete SCI are able to become

7 PSYCHOGENIC SEXUAL AROUSAL IN WOMEN WITH SCl, Sipski 817 subjectively psychogenically sexually aroused; however, the lack of sensation in the genital region alternates the effectiveness of additional tactile stimulation during sexual arousal. These results contrast with those observed in able-bodied women who showed progressive increases in subjective sexual arousal from psychogenic to psychogenic/reflexogenic sexual stimulatien. Similar to subjective sexual arousal, the pattern of vaginal vasocongestion showed a significant increase in vaginal pulse amplitude with isolated psychogenic sexual stimulation in able-bodied subjects. Furthermore, this vaginal vastcongestion was increased with the addition of tactile clitoral stimulation. In contrast, women with complete SCIs did not exhibit an increase in vaginal pulse amplitude with isolated psychogenic sexual stimulation; however, they showed a similar response to able-bodied subjects with the addition of tactile clitoral stimulation. These results support the hypothesis that female subjects with complete SCI at T6 and above are unable to achieve psychogenic genital vasocongestion because of the interruption of neurological pathways at their level of injury. In contrast, they are able to reflexively achieve genital vasocongestion through the addition of tactile stimulation to the psychogenic stimulation. In contrast to genital measures, the pattern of cardiovascular responses to sexual arousal were generally similar in SCI and non-sci subjects. Heart rate responses were not significantly different between able-bodied subjects and subjects with complete SCI. Both groups showed increased heart rates with audiovisual stimulation that were not augmented by manual stimulation. These elevated heart rate responses are expected during the arousal phase of sexual responsej Furthermore, because the autonomic innervation for the sinoatrial node originates through the middle cervical ganglia and stellate ganglia t~ this nervous pathway should remain completely intact in some of our SCI subjects and at least partially in others. Thus, with this sympathetic pathway intact we should expect similar heart rate responses between able-bodied subjects and those with complete SCI. Overall systolic blood pressure responses were not significantly different between able-bodied subjects and subjects with comp][ete SCI. There were, however, two exceptions to this statement. Isolated psychogenic sexual stimulation produced a significant increase in blood pressure in able-bodied subjects but not in those with complete SCI. However, the addition of tactile to the psychogenic stimulation resulted in a significant increase in blood pressure in both groups. Review of data showed considerable variability in SBP responses within the SCI group, which may have contributed to the lack of significance in the first condition. With the addition of tactile to psychogenic sexual stimulation in the SCI population two explanations can be offered for the increased blood pressure. The first is that the elevated blood pressure was related to increased sexual arousal. Alternatively, it is possible that tactile clitoral stimulation led to stimulation of the sympathetic outflow below the level of injury, with resultant increased blood pressure. In this case, because the SCI subjects did not exhibit increased subjective arousal we hypothesize that the blood pressure elevation was at least in part caused by direct clitoral stimulation. Although our subjects did not exhibit clinically significant hypertension, severe elevation of blood pressure has been reported in an SCI woman who stimulated herself to orgasm s and there are many women with SCI who complain of headaches and dysreflexia with sexual activity. Variations in respiratory rate were generally similar between SCI subjects and able-bodied controls. The exception to this was that during baseline, and throughout the recording period, able-bodied controls had higher respiratory rates. However, respiratory change scores did not show any significant differences between these groups. In summary, respiratory rate responses in women with complete SCI at T6 and above seem to be similar to those of able-bodied women. This is consistent with other nongenital responses during sexual arousal. In summary, this research supports the hypothesis that female subjects with complete SCI at T6 and above exhibit reflexive genital responses but not psychogenic. As such, it supports the anecdotal statements that previously indicated that women with complete SCIs would be able to achieve reflex but not psychogenic lubrication. 4'5 Furthermore, it is consistent with results of our previous self-report study in which no complete paraplegics or tetraplegics indicated the ability to achieve psychogenic lubrication, rather they indicated the ability to achieve reflex lubrication alone or a combination of reflex and psychogenic lubrication. 7 Their ability to become subjectively sexually aroused remains, with the exception that genital self-stimulation does not further augment sexual arousal. Other nongenital physiological responses were generally similar to those of able-bodied subjects. Further research is ongoing in this area to determine how women with incomplete high levels of SCI respond to similar stimulation. Additional work in progress in this laboratory is designed to determine the physiological components associated with orgasm in women with SCI. 12 Future research goals are to assess what the responses are in women with levels of injury below T6. Moreover, the ability of women to achieve psychogenic lubrication with specific patterns of neurological damage needs to be examined. Through these methods, we should be able to determine how different patterns of neurological injuries relate to the preservation of reflex and psychogenic vaginal lubrication. The study of men with SCI has been fundamental to an understanding of the neurophysiology of erection] 3 Likewise, studying women with SCIs will add substantially to our understanding of the neurological pathways responsible for psychogenic and reflexive sexual arousal in able-bodied women. This information should also help us to understand how other neurological disorders might affect specific components of the female sexual response cycle. Acknowledgement: Grateful acknowledgment is made to Steven Kirshblum, MD, for conducting the anal sphincter electromyography and somatosensory evoked potential testing on all subjects. Acknowledgement is also given to Jeffrey Alexander, MS, for his engineering consultation. Maureen Keogh and Dottie O'Neil are acknowledged for their efforts in data collection and entry. Thanks also to Susan Gilbert for her assistance in manuscript preparation. References I. Harvey C, Rothschild BB, Asmann AJ, Stripling T. New estimate of traumatic SCI prevalence: a survey-based approach. Paraplegia 1990; 28:53%44.

8 818 PSYCHOGENIC SEXUAL AROUSAL IN WOMEN WITH SCl, Sipski 2. Stover SL, Fine PR. The epidemiology and economics of spinal cord injury. Paraplegia 1987;25: Comarr AE, Vigue M. Sexual counseling among male and female patients with spinal cord and/or cauda equina injury. Am J Phys Med 1978;57: Berard EJJ. The sexuality of spinal cord injured women: physiology and pathophysiology. A review. Paraplegia 1989;27: Sipski ML. Spinal cord injury: what is the effect on sexual response? J Am Paraplegia Soc 1991; 14: Charlifue SW, Gerhart KA, Menter RR, Whiteneck GG, Manley MS. Sexual issues of women with spinal cord injuries. Paraplegia 1992; 30: Sipski ML, Alexander CJ. Sexual activities, response and satisfaction in women pre- and post-spinal cord injury. Arch Phys Med Rehabil 1993; 74: Sipski ML, Komisaruk B, Whipple B, Alexander CJ. Physiologic responses associated with orgasm in the spinal cord injured female [abstract]. Arch Phys Med Rehabil 1993;74: American Spinal Injury Association: International standards for neurological and functional classification of spinal cord injury--revised Chicago: American Spinal Injury Association, Masters WH, Johnson VE. Human sexual response. Boston: Little, Brown, Downey JA, Myers S J, Gonzalez EG, Lieberman JS. The physiological basis of rehabilitation medicine second edition. Butterworth, Heinemann, Sipski ML, Rosen R, Alexander C. Physiologic studies of sexual responses in spinal injured females. 33rd Annual Scientific Meeting of the International Medical Society of Paraplegia Programme & Abstracts 1994; Bors E, Comarr AE. Neurological disturbances of sexual function with special references to 529 patients with spinal cord injury. Urol Surv 1960; 110: Suppliers a. Dantec Medical, Incorporated, 3 Pearl Court, Altendale, NJ. b. Grass Instruments, PO Box 516, 101 Old Colony Road, Quincy, MA. c. Farrall Instruments, PO Box 1037, Grand Island, NE. d. Keithley Data Acquisition, 440 Myles Standish Boulevard, Taunton, MA. e. PC Problem Solvers, 112 Prospect Street, Westfield, NJ. f. MathWorks Incorporated, 24 Prime Parkway, Natick, MA. g. Criticare Systems Inc., PO Box 26556, Milwaukee, WI. h. SPSS Incorporated, 444 North Michigan Avenue, Chicago, IL.