Summary Article
Sexual Function Following Burn Injuries: Literature Review Atisha A. Pandya, BSc,* Helen A. Corkill, RN,† Ioannis Goutos, BSc (Hons), MBBS (Hons), FRCSEd (Plast)† Sexual function is a profound facet of the human personality. Burns due their sudden and devastating nature can have longstanding effects on intimate function by virtue of physical sequelae as well as alterations in body image and perceived desirability. A considerable number of patients encounter problems with intimate function in burns rehabilitation; nevertheless, the topic appears to be poorly addressed in specialist centers worldwide. Review of the literature suggests that a number of parameters can affect the quality of sexual life following burn injuries including age at the time of injury, location, and severity of the burn as well as coping mechanisms employed by the individual survivor. Addressing issues of intimacy relies on awareness, education, and a holistic approach on behalf of the multidisciplinary team members and, to this effect, recommendations are made on managing sexual function concerns in burns rehabilitation. (J Burn Care Res 2015;36:e283–e293)
Human sexual function has five discreet components, namely1, •• Sensuality (need to be conscious of and comfortable with own body through the five senses) •• Intimacy (need and ability to experience and enjoy emotional closeness with others and have this closeness reciprocated) •• Sexual identity (the individual’s sexual orientation, preferences, and gender roles) •• Sexualization (process of emphasizing the sexual nature of an individual), and •• Reproduction Burns are sudden and potentially life-changing injuries, which can have profound and long-lasting effects on the victim’s life. The consequences of a burn can be physical, imposing functional limitations, as well as psychosocial, affecting self-esteem and body image.2 From the *Kings College London Medical School, United Kingdom; and †Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Aylesbury, United Kingdom. Address correspondence to Ioannis Goutos, BSc(Hons), MBBS(Hons), FRCSEd(Plast), Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Mandeville Road, Aylesbury, Buckinghamshire HP21 8AL, United Kingdom. Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000196
Body image can be defined as the internalized mental picture of an individual’s physical appearance, which is influenced by perceived stereotypes of physical attractiveness, health, and function. This internalized mental picture is inseparable from sexuality, since the way in which a person perceives oneself has a huge impact on the way in which he/she partakes in intimate activities.3 Several studies have highlighted the strong link between a negative body image and low levels of sexual function in nonburn cohorts,4,5 and it therefore comes as no surprise that a number of reports in the burns literature support similar findings.6–9 Nevertheless, the subject has not attracted a lot of interest in the literature, and it appears that sexual function concerns postburn are not adequately addressed in specialist centres.10,11
METHODOLOGY The aim of this review is to examine all the existing knowledge on sexual function following burns. For the purpose of this work, the term sexual function is used in the widest sense to incorporate concepts including sexual esteem, desire, genital or nongenital intimate activity, as well as reproductive functions. We undertook an extensive English literature search using a number of databases: PubMed, ISI Web of Science, and CINAHL, and retrieved all articles pertinent to the topic to date. We present the various e283
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assessment tools employed to assess sexual function and analyze parameters affecting its quality following injury. We conclude by formulating recommendations for health professionals as to how best address these sensitive intimate issues in burns rehabilitation.
BURN INJURIES AND EFFECTS ON SEXUAL FUNCTION A variety of factors have been proposed in the literature as contributing to sexual dysfunction in burns patients and can be classified into the following major groups6: a) Psychopathological factors. Anxiety and posttraumatic stress disorder (PTSD) are common conditions affecting burn survivors and have a state of hyperarousal as a common denominator. The associated sympathetic overdrive has been found to affect the physiology of the sexual response by interfering with the arousal phase of the sexual response as well as the adrenergically mediated emission phase of orgasm.12 b) Psychodynamic factors. A fulfilling sexual life intimately links with a positive body image, which can be severely disturbed as a result of the injury and treatment received. In physical terms, burns involve a forceful change in appearance. Furthermore, the technical ward environment and specialist equipment employed for repeated medical/nursing procedures (involving exposed bodily parts) entails an element of dehumanization and redefinition of bodily boundaries. All of these factors have the potential to disturb the perception of body image and sexuality to a significant extent.7,13 Additionally, it is widely recognized that any significant physical trauma can result in psychodynamic regression. This state is highly reminiscent of “infantile dependence” and manifests itself with a demanding attention-seeking behavior, an apparent inability to make autonomous decisions as well as irrational childlike rejection of any sexualized thoughts or activities.14,15 c) Physiological aspects. Large burn injuries are associated with considerable hormonal imbalances, whose physiological effects can interfere with sexual function/reproduction. For example, the augmented release of stress hormones, including catecholamines and cortisol, interferes with sex hormone release leading to abnormalities of menstruation during rehabilitation.12 d) Medication side effects. Polypharmacy is common in burns rehabilitation and a large
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proportion of medications used ranging from antihypertensives (e.g., β-blockers) to psychotropic medications (e.g., antidepressant and anxiolytics) can interfere with sexual function. This occurs via a number of mechanisms including a central sedative action, the direct effect of drugs on peripheral neurotransmitters (α-adrenergic effect on erectile tissue), and hormonal imbalances (prolactin increase due to dopamine-blocking agents).6,16 e) Surgical issues. Burn injuries involving the external genitalia can have devastating effects on sexual function due to the damage to erectile and surrounding fascial tissues. The male reproductive organs are more prone to injury due to their external anatomical characteristics. Additionally, the physical morbidity from the surgical management of penile burns can be considerable; debridement with skin grafting can result in loss of the Dartos fascia, which normally provides an optimal gliding surface during sexual activity.8 f) Sensory issues. Wounds and scars can be accompanied by a number of significant sensory symptoms, including dysesthesia (altered sensation), hypoesthesia (lack of sensation/decreased sensation), and hyperesthesia (increased sensation). All of these can have a significant impact on intimate functioning, since tactile sensation is an integral component of sensual activity.17
TOOLS EMPLOYED IN THE ASSESSMENT OF SEXUAL FUNCTION POSTBURN There exist a limited number of literature reports appraising the quality of sexual function postburn. In broad terms, researchers have used varied methodology, which can be divided into marital satisfaction questionnaires, sexuality scales, and quality of life assessment tools.18–32
Marital Questionnaires Locke-Wallace Marital Adjustment Scale. This scale has been designed to determine marital satisfaction after injury or medical intervention. It comprises a 15-item questionnaire, which covers a number of aspects of married life including affection and sexual relations.18 Maudsley Marital Questionnaire. This comprises 20 Likert-scale questions, which evaluate three domains, namely marital (10 items), social (5 items), and sexual satisfaction (5 items). A low overall score indicates high marital satisfaction.19 Both of
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the above have been used in single burn literature reports, and their main limitation is that they apply to married individuals and hence may be considered out dated in an era of cohabitation rather than traditional marriage partnership status.
Sexuality Questionnaires Burn Sexuality Questionnaire (BSQ). The BSQ is a comprehensive 24-item assessment tool, which attempts to determine the degree to which a burn survivor is able to interact comfortably in terms of sex drive as well as sexual activity. Seven parts are purely demographic, and the remaining 17 cover multiple aspects of sexuality including domains of “body image,” “social comfort,” and “intimacy.” The BSQ has been reported to promote a good response from participants of a single study, who expressed appreciation at the topic of sexuality being addressed.20 This assessment tool has been recently translated to the Portuguese language21; nevertheless, it has not been widely adopted since it lacks validation as yet. Sexuality Scale (SS). This scale, originally developed in 1989 by Snell and Papini, evaluates three aspects of human sexuality, namely: sexual esteem (positive regard/confidence in the capacity to experience one’s sexuality in a satisfying way), sexual depression (experience of negative feelings regarding sex life), and sexual preoccupation (tendency to think about sex to an excessive degree).22 It has been found reliable and valid in predicting sexual behaviors in both sexes in nonburn cohorts23 and has been used in a single burn study of a male cohort.24 “What Young People Believe and Do” Questionnaire. This is an assessment tool used to assess sexual attitudes and behaviors in adolescents between 13 and 19 years of age.25 A shorter/revised version of it has been used in two burn studies appraising sexual attitudes in patients who sustained an injury during childhood/puberty.26,27 The main limitation of this tool is the restricted age range it applies to.
Quality of Life Assessment Tools Quality of Life Survey. A 9-point Likert scale is employed in this survey to allow individuals to rate their ideal versus actual sexual performance. The survey covers a wide variety of intimate aspects including sexual thoughts, nongenital intimate contact, as well as sexual intercourse and has been used in a single burn publication.28 Burn Specific Health Scale (BSHS). The BSHS is a 114-item outcome scale, which was subsequently abbreviated to 80 items, the Abbreviated Burn Specific Health Scale (BSHS-A). In this format, it
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assesses four aspects: physical, mental, social, and general, and these are further subdivided into eight domains, one of which is sexual activity. Despite being an abbreviated scale, the widespread use of the BSHS-A was still being hampered by its large size, and a further revision to a 31-item scale, the revised BSHS (BSHS-R) was produced. This scale contains seven domains, one of which is Interpersonal Relationships. However, this revised scale fails to encompass some relevant aspects of burn injury, and more specifically, items dealing with hand function and sexuality are excluded.29 The latest modification of the scale is in the form of the brief version (BSHS-B), which is a 40-item scale with nine domains which include interpersonal relationships and sexuality. The BSHS-B is described as a valid but shorter alternative to the BSHS-A and has been translated and validated in a variety of languages.30 Of the 40 questions, only three are directly related to sexuality, in particular the physical aspects of sex, namely: I feel frustrated because I cannot be sexually aroused as well as I used to be. I am simply not interested in sex anymore. I no longer hug, hold, or kiss. These questions although focusing on sexual activity, do so at a rather superficial level and are open to interpretation and therefore possible misunderstanding. For example, the statement “I no longer hug, hold, or kiss” does not specify whether it refers to sexual activity or social/familial interactions. Patients may be unsure how to answer the statements, and their ambiguity may result in some patients concerns about sexual matters not being fully highlighted. The BSHS-B, despite its limitations, is considered to be a valid and useful assessment tool for determining quality of life postburn and is indeed the most frequently used tool.9,17,31,32 It becomes apparent that a range of different assessment methods has been used in the burns literature to appraise levels and quality of sexual functioning following injury. Main limitations of the different tools relate to their applicability to certain age ranges and partnership status. Additionally, their lack of standardization and validity presents particular challenges in the study of sexual function.
FACTORS THAT PREDICT SEXUAL DYSFUNCTION A variety of factors appear to predispose to sexual dysfunction in burn injuries (Figure 1).
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Gender
Age at time of injury
Relationship status
Location of burn
Total burn surface area / depth
Coping mechanisms & personality Mechanism of injury
Figure 1. Patient- and injury-related parameters affecting the quality of sexual function following burn injuries. Background depicts Eros, red-figure bobbin, ca. 470 BC–450 BC, found in Athens. Original kept at the Louvre Museum, Department of Greek, Etruscan and Roman Antiquities, Sully wing, Campana Gallery (CA 1798), photographer: Jastrow (2006).
Gender The effect of gender on the quality of sexual function postburns is intriguing. A recent Australian study analyzed BSHS-B questionnaire responses in the sexuality and body image subdomains of 362 individuals (mean age: 39 years, mean TBSA of 10.7%, and TBSA range: 0.25–65%).17 Results suggest sexual arousal is affected to a similar extent in both males and females at 6 and 12 months postinjury. Loss of sexual interest at 12 months was more pronounced in females (12.3% males vs 31.8% females) as manifested by changes in hugging, holding, and kissing behavior. In terms of the body image/appearance domain, females reported more severe disturbances in body image across all stages of rehabilitation (1, 3, 6, 12 months) with especially significant changes at 12 months. The results from the study point toward females reporting greater levels of body image disturbances, and these potentially increase in severity over time during their rehabilitation. Similar results have been reached from a large study of 865 burn patients treated at the Royal Perth Hospital, with women scoring lower than men in the sexuality, body image, affect, and relationships domains32; this finding was more pronounced in major burn injuries.
A review of 54 patients in a U.S. center assessed postburn sexual function by asking patients to score their ideal versus actual performance in six different domains. A nine-point scale was employed based on the frequency of various intimate activities (including fantasies and intercourse) from 0 = not at all to 8= more than three times daily. Females expressed statistically significant lower levels of sexual satisfaction compared to males (52.6 vs 82.5%, P < .01), and this appears to strongly correlate with disturbances in body image.28 A prospective study in an Indian burn center involving 544 patients assessed quality of life using the Maudsley marital questionnaire 6 months postburn. The cohort comprised burn patients between 15 and 65 years in a stable married relationship with no preburn psychosexual disturbances. The control group consisted of 500 patients attending outpatient departments for nonburn-related conditions with the same inclusion criteria. A total of 52.94% of burn patients were found to be sexually dissatisfied, a result statistically significant in comparison to the control group (X2 = 117.8945; df = 1; twotailed P < .0001) with the majority of the dissatisfied patients being men (75.69%). Additional findings
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included the positive association between duration of hospital stay as well as between painful/unstable scars (P ≤ .0001) and penile deviation (P ≤ .0002) with sexual dissatisfaction. The authors attributed the gender difference in sexual dissatisfaction to societal/cultural attributes of masculocentricity. Men were deemed more vocal about their sexuality and open to discussions about postburn changes, whereas women were found to be reluctant to discuss their sexual lives and deemed to be more concerned about acceptance into society, child welfare, and household issues.19 The inference from the studies points toward their being a cultural filter in terms of reporting sexual dysfunction, with men in predominantly musculocentric cultures being more open toward sexual issues. Additionally, it is possible that, by virtue of their predominantly external nature, male genital organs are more prone to injury and the physical sequelae are reported more abundantly, whereas in females, issues of body image are more likely to be of prime concern depending on the nature of the tool employed to assess sexual function.
Age at Time of Injury Age at the time of injury is another interesting variable when examining factors that may predispose an individual to psychosexual problems. Evidence exists to indicate that patients with pediatric burns tend to have better adjustment/self-esteem and less sexual dysfunction than adult burn survivors.33,34 A study investigated sexual attitudes and behavior of 92 young adults burned (>30% TBSA) as children.26 The mean age at the time of the survey was 21 ± 2.7 years with burn injuries having occurred 14.2 ± 5.4 years earlier. The respondents completed the “What Young People Believe and Do” questionnaire, which consists of 76 questions relating to sexual knowledge, beliefs, behavior, and relationships. Patients were included if they were at least 2 years postburn and if the injury had occurred before the age of 18. The study hypothesis that individuals with burn scars have differences in sexual attitudes and limited sexual activity was disproved. The sexual attitudes and behaviors were comparable to the general population with the vast majority of respondents reporting significant sexual experience to suggest favorable psychosexual adjustment of children with major burns. A Finnish study of 91 patients, who sustained pediatric burns (90.1% scalds, mean TBSA 11.9%, median age of 1.4 years) has identified these injuries to be associated with transient long-term psychosexual
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sequelae, with 11 adult patients (20.8%) reporting difficulties in the commencement of sexual contacts at puberty. However, only one reported suffering sexual impediment later on in life.35 A comparative retrospective study in Texas examined the impact of scars on adolescent sexual development.27 Nineteen patients between 13 and 20 years (mean 12.23 years) at least 1 year following disfiguring burn injuries (TBSA range: 7–85%) completed a sexuality questionnaire (“What Would Young People Believe and Do,” revised). The results of the study were compared with reports on sexual beliefs and attitudes amongst the general adolescent population within the United States of America. The results indicated that those with disfiguring burn scars have thoughts, behaviors, and feelings that are similar to those of nonburned adolescents. They also indicated that the severity of disfigurement bore no correlation to the sexual behaviors of the teenagers, and additionally there was no correlation between burn severity and time of first intercourse or nongenital intimate touching. Interestingly, the study reports that 56% were thrilled with their first sexual experience compared to only 30% of the nonburned group. An Australian study using the Burn Specific Health Scale-Brief Version (BSHS-B) on 362 individuals found that the older the patient is at the time of injury, the greater the likelihood that he/she is to report some level of impact in sexuality-specific questions.17 Review of the relevant literature confirms that individuals burned during childhood/puberty appear to integrate successfully in terms of their sexual function.17,26,27,33–35 There are various hypotheses as to how this might occur including the fact that growing up with scars calls upon the individual to integrate their injury and physical sequelae within their identity as opposed to having to redefine their body/ sexual image in the context of a burn injury.36 Furthermore, if the burn injury precedes the very first sexual encounter, individuals have little to compare their first experiences to mentally or physically, and this may mediate better psychosexual adjustment.
Mechanism of Injury A study among 22 patients with electrical burns (at an average of 5.3 ± 4.9 years postinjury) using the BSHS-B revealed particularly low scores in the sexuality domain for patients with high-voltage burns (≥ 1000 V). Patients with large TBSA burns were found to score lower on the sexuality domain as well as body image. Impairments in sexual functioning
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as well as affect and work satisfaction appeared to persist at a substandard level over a long period of time (5 years).31 Contributory factors toward these findings include the well-described detrimental neuropsychiatric effects associated with electrical injuries (with depression being one of the commonest sequelae) as well as damage to nerves and blood vessels, which can lead to ischemia and pain especially in areas of erectile tissue.37
Burn Location and Scar Visibility The area of the burn appears to be a key element when looking at the risk factors involved in sexual dysfunction following burns.8,19,38 A small study of 10 patients (average TBSA 28%, mean age of 41) with penile burn injuries identified that these injuries contribute to considerable physical and psychological morbidity. Three out of 10 patients with skin grafts to the penis were disappointed with the functional results to the extent that two did not resume sexual activity at all and one resumed 12 months after injury. The latter patient, nevertheless, found his function unsatisfying despite normal apparent erectility. The effect of penile burns on sexual function in this study appears to relate not only to the functional effects of surgery/scarring but also to the lack of sex drive secondary to changes in body image.8 A prospective study by Ahmad et al investigated the factors that hamper the sexual life of 544 burn patients, who were in an ongoing relationship for at least a year prior to injury. The results show that pain over burnt genitalia or perineal regions during sex is one of the main issues amongst patients complaining of sexual dissatisfaction 6 months postburn. Additionally, a positive association between sexual dissatisfaction and penile deviation was identified (P ≤ .0002) in the cohort. Alongside the loss of libido, humiliation at exposure and dyspareunia were all very important factors also quoted as contributors to an unhappy sex life.19 Renshaw et al identified that burns on the inner thigh or near the scrotal area in men can lead to impairment of sexual function. In women, burns to the breast were considered to be mostly disfiguring amongst the victims, with lack of perceived attractiveness and poor self-confidence being important issues.38 These findings suggest that areas of burn close to the sexual organs but not involving the genitals themselves can have significant negative impact on a patient’s sex life. A closely related parameter associated with burn site is visibility of the resulting scarring, and it is
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interesting to investigate how it affects psychosexual behavior amongst burn survivors. A Finnish study of 91 patients who sustained pediatric burns identified that 20.8% of patients reporting difficulties in starting sexual contact at puberty had trunk scarring, and their sexual difficulties were not associated with scar visibility.35 This is not particularly surprising since it is known from other studies that hidden scars in children can lead to poor adjustment since individuals live with the fear of discovery and subsequent guilt. As a result, the whole process of body image revision is either delayed or remains incomplete.39 The effect of site visibility on sexual functioning may be different in adult burn victims. An Australian study found that in women there is a correlation between lower BSHS-B scores (body image and sexuality domains) and specific burn sites (limbs and face).32 This finding, which links sexual dysfunction to visible burned body parts, corroborates with results from other work suggesting that women’s reporting of sexual dysfunction relates predominantly to issues of body image.17 We propose that this may occur because females have to redefine their body image in the context of the increased cultural pressures to conform to beauty ideals, and hence it is not surprising that this is particularly challenging in the presence of visible scarring.
Burn Severity: TBSA and Depth A small study among 40 male burn survivors treated and discharged over an 11-year period in a Southeastern U.S. unit identified that there is no correlation between burn injury severity and sexual esteem/ depression and preoccupation.24 This initial finding was confirmed in a similarly small study of 54 patients, which showed no statistically significant differences in sexual satisfaction with respect to burn size.28 The first study suggesting a positive correlation between TBSA and worse sexuality score refers to a small group of 22 patients with high-voltage electrical burns (>1000 V). Patients with larger burns (>20% TBSA) had significantly lower sexuality scores than those with less extensive burns.31 Negative correlation has been identified in another report between sexual activity and percentage full thickness injury, the number of surgeries, as well as the length of hospital stay.40 A very recent study of 865 Western Australian patients found a positive association between decreasing scores for the sexuality domain of the BSHS-B and increases in TBSA in both male and female patients.32 The conclusion is that there appears to be an emerging strong link between TBSA and levels of sexual dysfunction.
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Coping Mechanisms/Personality Traits A variety of personality traits have been associated with sexual concerns/dysfunction. Patients with avoidant coping mechanisms (i.e., those who avoid contact with people/activities, are withdrawn/reluctant to change, and have restricted emotional expression) score significantly lower in the BSHS-B scale for the body image, affective, relationship, and sexuality domains compared to adaptive copers (outgoing attitude using emotional support and optimism as well as a hopeful approach to the future).41,42 Additionally, high levels of neuroticism have been linked with worse self-reported scores in the sexuality domain of the BSHS-B.43,44
Relationship Status The literature suggests that patients who are in a relationship prior to their injury score higher in the affect and relationship domains of the BSHS-B.32 Additionally, negative correlation has been found between sexual activity and living alone in a cohort of 95 patients, which studied self-reported sociodemographic factors and injury-specific factors determining long-term physical and psychosocial health.40
ADDRESSING SEXUAL DYSFUNCTION/RECOMMENDATIONS FOR BURN CARE PROFESSIONALS Issues surrounding sexual function are particularly delicate, and the way these are approached needs careful consideration. Important parameters in addressing sexual function issues relate to when, who, and how these issues are raised and managed. We review the current state of knowledge in the literature and propose recommendations for burn professionals.
When? The timing at which sexual issues in burns rehabilitation are broached and addressed is of vital importance. A seven-stage model for the psychological recovery of burns victims has been proposed by Watkins and is highly applicable to the exploration of issues surrounding sexual function.45 First stage: survival anxiety lasting for 1–2 weeks; the patients’ focus appears to be centered on evaluating the ability to survive the injury. Second stage: pain perception persisting for 6–8 weeks; this stage follows realization of the ability to survive the injury and centers on perceived pain and its relief. Third stage: search for meaning; patients search for an emotionally acceptable cause and effect rationale.
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Fourth stage: investment in recuperation; motivation and interest in self-care is typically heightened, and as individuals attempt more unassisted tasks, pride in self develops and verbalizes. Fifth stage: acceptance of losses; patients comprehend long-term losses as a result of the injury. Sixth stage: involvement in rehabilitation, which may take the form of further surgery which entail further reexamination and redefinition of self. Seventh stage: reintegration of identity through admission of losses and attempt to resume preburn functioning, through awareness directed at the differences between pre- and postburn experiences. The above model is key to allow burn professionals to gauge an appropriate time to introduce the sensitive topic of intimate function. Patients with big injuries undergo a prolonged period of physiological stabilization and hence are unlikely to be concerned with their sexual function until they reach the later stages of psychological adaptation (fourth stage— investment in recuperation). On the contrary, in patients with smaller injuries, the above model might not be as applicable (especially in terms of its timescale), and it may be appropriate to introduce the topic earlier on especially with injuries affecting erotogenous zones. In essence, healthcare professionals need to be aware that these issues may surface at different stages of rehabilitation and be prepared to act upon them with a positive, empathetic, and unbiased attitude.
Who? The question of who should be responsible for initially introducing the topic of sexuality in burns rehabilitation has been investigated in two literature reports. The first used a 28-item questionnaire completed by 71 North American burn care practitioners. Nearly half (47%) reported that there is no specific staff designated to discuss sexuality and intimacy, and 62% reported having received no specialized training on sexual topics in their units. Thirteen percent of the respondents believed it is solely the nurses’ responsibility to handle the issue with the majority agreeing that it should not be the patients who initiate such discussions. Only 14% of the burn practitioners in this study felt “very comfortable” to initiate such communications, and interestingly, the same percentage indicated satisfaction with the way their own body “looks and feels.”10 A Brazilian study employing the same methodology and questionnaire (completed by 120 practitioners from 41 centers) identified that only 28% of respondents were comfortable initiating discussions, with 34.7% indicating they were comfortable with
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their own body image and sexuality. The majority (76.6%) believed it to be the responsibility of the psychologist to discuss sexual and intimacy issues.11 It becomes apparent from these studies that there is marked hesitancy among healthcare professionals in initiating discussions pertaining to sexual health and function. This is not surprising given that different individuals have their own biases toward intimacy and many factors can contribute to discomfort in discussing sexual issues. These may include culture, religion, lack of training, age, as well as sexual orientation.10,11 Nevertheless, a reluctant attitude is likely to make burn patients feel disempowered to vocalize concerns independently, and it may contribute to the underreporting of this important subject in burn rehabilitation. Patients encounter many different members of the multidisciplinary team during their treatment timescale. Nursing staff might be in a particularly privileged position to broach and discuss the delicate subject of sexual function postburn. They are involved in round the clock care for the burns patient and consequently have the potential to develop a close trusting relationship, which is necessary to allow concerns to surface and be dealt with. Additionally, psychologists are equally empowered given their training to explore issues of sexual function with patients. In the United Kingdom, the National Network for Burn Care has recently outlined that all burn services should provide psychological care to burn-injured patients and their families as part of the National Burn Care Standards framework.46 The overwhelming majority of burn services in the United Kingdom currently offer routine psychosocial screening through dedicated psychologists; however, this does not routinely broach psychosexual topics.47 We believe that any willing, open-minded, and well-informed member of the multidisciplinary burn team could act as an important link toward identifying patients concerned about their sexual function and arrange appropriate follow-up with a professional (e.g., qualified sex therapist) according to the nature of the problem.
How? A particularly gentle way of introducing the concept that sexual function can be discussed openly in burns rehabilitation is by incorporating questions of sexuality in the initial assessment of patients’ admission for treatment. This approach obviously may not be appropriate in patients with very large or very small injuries. Therefore, professional discretion needs to
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be applied in this respect. Incorporating the topic within the initial encounter and obtaining a detailed sexual health history may go a long way in normalizing discussions of intimacy and “opening” the door to addressing specific concerns. Additionally, it allows the burns team to have a useful baseline for later sexual function assessments in rehabilitation. History taking should ideally use open (e.g. “tell me about your sexual activity”) as opposed to closed questions (i.e., “how often do you have sex normally”), since the latter have an element of assumptive disposition. Creating a relaxed private environment is crucial for these discussions; this can be accomplished by using a private therapy room and acknowledging the challenges involved in discussing intimate concerns. It is important to acknowledge that issues of sexual functioning may surface at any time during recovery and all involved disciplines need to be prepared to prompt, respond, and follow up appropriately. For example, the therapy outpatient setting may be appropriate to introduce/discuss this sensitive topic in a variety of ways as it relates to recovery from the physical effects of scarring. The PLISSIT model is a tool designed to assist healthcare professionals in discussing sexuality with patients. It takes its name from the four stages of Permission, Limited Information, Specific Suggestions, and Intensive Therapy.48 It is a model that appears to deal specifically with sexual concerns and, due to its flexible nonprescriptive nature, is easily adaptable to individual needs. The first stage, Permission, involves making patients and their partners aware of being able to ask questions and raise issues on matters of sexual behavior and intimate feelings. The second stage, Limited Information, involves giving the patient information that is applicable to their concerns in an anticipatory or direct question– answer format. In the third stage, Specific Suggestion, information is given to patients and their partners on behavioral changes that can help them to relieve anxiety and help generate patient/partner-derived solutions. This can be as simple as providing advice on how to protect graft sites during intercourse. The first three stages of the model allow intervention by nurses and other health professionals. The final stage, Intensive Therapy, involves referral to a sex therapist if the patients concerns have not been satisfactorily addressed in the first three stages. Whilst the PLISSIT model purports to need only the input of a trained sexual therapist in its final stage, the successful interpretation of the information
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derived from patients in its earlier stages and the subsequent advice that is given, requires training in sexual health, together with the confidence to address and successfully discuss such topics.48 This serves to highlight the importance of implementing training in sexual matters for staff members from each discipline and the need to increase awareness of this important subject matter so that the burns multidisciplinary team is able to respond to concerns appropriately.
Other Important Aspects of Psychosexual Care Medical/Surgical Treatment. Burn injuries involving erogenous zones need to be treated with particular care. Tissue-sparing approaches avoiding aggressive debridement of potentially viable tissue are indicated in an attempt to save as much erectile and fascial tissues as possible. Additionally, donor areas, when possible, should be planned in such a way as to avoid erogenous zones (e.g. inner thigh), given the effect they may have on intimate functioning by altering the tactile characteristics of the skin.38 Additionally, pharmacotherapy needs to be tailored to avoid a detrimental effect on sexual function (e.g., judicious use of agents with erectile side effects).6 Sensory Symptom Management. The effective treatment of unpleasant sensory symptoms (e.g., pain) in the initial stages of admission has been shown to be vital for the establishment of a trusting bond between staff and patients. Patients tend to perceive the provision of adequate analgesia indicative of staff concern for their welfare; hence, the best time to establish rapport and trust is during the first hours of a patient’s admission.7 This also applies throughout rehabilitation, where treatment of pain and itch should be a priority. Involvement of Partners. For burn patients in a relationship at the time of their injury, it is important to consider the involvement of their partner in psychosexual rehabilitation.19 Partners should be involved in discussions early on and become aware of the different stages that their “significant other” may go through during their recovery. These may include signs of withdrawal, avoidance, or irritability aimed at the partner. Furthermore, burns patients may use inappropriate or sexually overt comments and gestures toward their partner as a way of “testing of rejection.”7 It might also be prudent to encourage involvement of partners in skin contact. This can range from the use of simple touch during the rather
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“dehumanizing” critical care setting as well as during the scar rehabilitation phase. Moisturizing and massaging their partner’s scars can help both parties to overcome hesitant attitudes and the “fear of rejection,” by familiarizing individuals with the different feel and texture of the skin before discharge. Engagement of the partner in scar rehabilitation is likely to exert effects extending into the psychosexual sphere.3 Appropriate touching communicates involvement, reassurance, and affection and goes a long way to reestablish tactile relationships as well as allowing the integration of two diverse roles (caregiver and lover) to develop. The concept of engaging the partner in scar management derives from well-established practices of “Sensate Focus.” This encourages individuals to take pleasure in experiencing the texture and form of their partner’s body through touch with a view to helping build trust and intimacy in a relationship where negative reactions to intimacy and sex may have developed as a result of the burn injury.49 Grooming. Encouraging patients to pursue grooming activities is likely to be important in helping improve their sense of wellbeing and facilitate readjustments in body image.
DIRECTIONS FOR FURTHER RESEARCH Given the considerable advances in burn care, the survival rate of patients has increased over the past decades and patients’ resulting quality of life measures attain prominent focus. Traditional measures of outcomes including morbidity, mortality, and length of stay are being replaced by more holistic patient-reported measures that seek to capture the overall burn patient journey experience and assess the long-term effects of injuries.50 Given the vital importance of a healthy sexual life, the quality of intimate functioning needs to receive appropriate attention in assessing long-term outcomes. One of the main areas that need further research is the standardization of sexual function assessment postburn. A validated tool, which incorporates all aspects of sexual function and is applicable to a wide age range and partnership status, is eagerly awaited. Awareness of the need to be open about sexual function as part of burns rehabilitation is another area that needs further work, and this can only be achieved with educational programs for staff from all disciplines within the burn multidisciplinary team. This training should concentrate on establishing an adequate knowledge base and improving self-awareness of the personal value systems of burn services staff; these are
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essential prerequisites to enable staff to communicate genuinely and therapeutically with patients on sexual matters.51 The concept of establishing a “sexual health link” professional in burn services is an attractive concept. These individuals having undertaken appropriate psychosexual training could become designated members of staff in burns services, responsible for addressing patients’ sexual concerns in an effective and knowledgeable manner.
CONCLUSION Sexual function is an integral part of an individual’s life. Burn injuries by virtue of physical and psychosocial sequelae can have a profound impact on intimate functioning. A variety of patient- and injury-related parameters have been found to affect the quality of sexual life following burn injuries. Awareness of this important subject and specialist training for burn services staff is imperative to enable patients to express their sexual concerns and for these to be addressed in a professional manner. The successful achievement of these aims is likely to result in better psychosocial outcomes for the burn-injured patient. References 1. Shaniff E, Yahmina E, Munro B. Sexuality and disability: the role of health care professionals in providing options and alternatives for couples. Sex Disabil 2001;19:267–82. 2. Fobair P, Stewart SL, Chang S, D’Onofrio C, Banks PJ, Bloom JR. Body image and sexual problems in young women with breast cancer. Psychooncology 2006;15:579–94. 3. Bogaerts F, Boeckx W. Burns and sexuality. J Burn Care Rehabil 1992;13:39–43. 4. Ussher JM, Perz J, Gilbert E. Changes to sexual wellbeing and intimacy after breast cancer. Cancer Nurs 2012;35:456–65. 5. Tepper MS, Whipple B, Richards E, et al. Women with complete spinal chord injury: a phenomenological study of sexual experiences. J Sex Marital Ther 2001;27:615–23. 6. Dobkin de Rios M, Novac A, Achauer B. Sexual dysfunction and the patient with burns. J Burn Care Rehabil 1997;18:37–42. 7. Whitehead TL. Sexual health promotion of the patient with burns. J Burn Care Rehabil 1993;14(2 Pt 1):221–6. 8. Balakrishnan C, Imel LL. Effect of penile burns on sexual function. J Burn Care Rehabil 1995;16:508–10. 9. Elsherbiny OE, Salem MA, El-Sabbagh AH, Elhadidy MR, Eldeen SM. Quality of life of adult patients with severe burns. Burns 2011;37:776–89. 10. Rimmer RB, Rutter CE, Lessard CR, et al. Burn care professionals’ attitudes and practices regarding discussions of sexuality and intimacy with adult burn survivors. J Burn Care Res 2010;31:579–89. 11. Piccolo MS, Daher RP, Gragnani A, Ferreira LM. Sexuality after burn in Brazil: survey of burn health-care workers. Burns 2011;37:1411–8. 12. Axelrod J, Reisine TD. Stress hormones: their interaction and regulation. Science 1984;224:452–9. 13. McCloskey JC. How to make the most of body image theory in nursing practice. Nursing 1976;6:68–72.
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14. van der Kolk BA, Fisler RE. The biologic basis of posttraumatic stress. Prim Care 1993;20:417–32. 15. Gunther M. Psychiatric consultation in a rehabilita tion hospital: a regression hypothesis. Compr Psychiatry 1971;12:572–85. 16. Gitlin MJ. Psychotropic medications and their effects on sexual function: diagnosis, biology and treatment approaches. J Clin Psychiatry 1994;55:406–13. 17. Connell KM, Coates R, Wood FM. Sexuality follow ing burn injuries: a preliminary study. J Burn Care Res 2013;34:e282–9. 18. Garts K, Garland S. Marital satisfaction of the post-rehabilitation burn patient. Occup Health Nurs 1983;31:35–7. 19. Ahmad I, Masoodi Z, Akhter S, et al. Aspects of sexual life in patients after burn: the most neglected part of post burn rehabilitation in the developing world. J Burn Care Res 2013; 34:333–41. 20. Cooper-Fraps C. Burn sexuality questionnaire. J Burn Care Rehabil 1985;6:426–7. 21. Piccolo MS, Gragnani A, Daher RP, de Tubino Scanavino M, de Brito MJ, Ferreira LM. Burn Sexuality Questionnaire: Brazilian translation, validation and cultural adaptation. Burns 2013;39:942–9. 22. Snell WE, Papini DR. The sexuality scale: an instrument to measure sexual-esteem, sexual-depression and sexual-preoccupation. J Sex Res 1989;26:256–63. 23. Snell WE, Fisher TD, Schuh T. Reliability and validity of the sexuality scale: a measure of sexual-esteem, sexual-depression and sexual-preoccupation. J Sex Res 1992;29:261–73. 24. Bianchi TL. Aspects of sexuality after burn injury: outcomes in men. J Burn Care Rehabil 1997;18:183–6; discussion 182. 25. Sorensen RC. Adolescent sexuality in contemporary America. New York: World Publishing; 1972. 26. Meyer WJ, Russell W, Thomas CR, Robert RS, Blakeney P. Sexual attitudes and behavior of young adults who were burned as children. Burns 2011;37:215–21. 27. Robert RS, Blakeney PE, Meyer WJ 3rd. Impact of disfiguring burn scars on adolescent sexual development. J Burn Care Rehabil 1998;19:430–5. 28. Tudahl LA, Blades BC, Munster AM. Sexual satisfaction in burn patients. J Burn Care Rehabil 1987;8:292–3. 29. Kildal M, Andersson G, Fugl-Meyer AR, Lannerstam K, Gerdin B. Development of a brief version of the Burn Specific Health Scale (BSHS-B). J Trauma 2001;51:740–6. 30. Pishnamazi Z, Rejeh N, Heravi-Karimooi M, Vaismoradi M. Validation of the Persian version of the Burn Specific Health Scale-Brief. Burns 2013;39:162–7. 31. Noble J, Gomez M, Fish JS. Quality of life and return to work following electrical burns. Burns 2006;32:159–64. 32. Connell KM, Phillips M, Coates R, Doherty-Poirier M, Wood FM. Sexuality, body image and relationships following burns: analysis of BSHS-B outcome measures. Burns 2014;40:1329–37. 33. Lawrence JW, Rosenberg LE, Fauerbach JA. Comparing the body esteem of paediatric survivors of burn injury with the body esteem of an age-matched comparison group without burns. Rehabil Psychol 2007;52:370–9. 34. Pope SJ, Solomons WR, Done DJ, Cohn N, Possamai AM. Body image, mood and quality of life in young burn survivors. Burns 2007;33:747–55. 35. Zeitlin RE. Long-term psychosocial sequelae of paediatric burns. Burns 1997;23:467–72. 36. Russell W, Robert RS, Thomas CR, Holzer CE 3rd, Blakeney P, Meyer WJ 3rd. Self-perceptions of young adults who survived severe childhood burn injury. J Burn Care Res 2013;34:394–402. 37. Pliskin NH, Capelli-Schellpfeffer M, Law RT, Malina AC, Kelley KM, Lee RC. Neuropsychological symptom presentation after electrical injury. J Trauma 1998;44:709–15. 38. Renshaw DC. Burn patients: emotional and sexual reactions. Med Aspects Hum Sex 1989;23:22–37.
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39. Stoddard FJ. Body image development in the burned child. J Am Acad Child Psychiatry 1982;21:502–7. 40. Moi AL, Wentzel-Larsen T, Salemark L, Hanestad BR. Long-term risk factors for impaired burn-specific health and unemployment in patients with thermal injury. Burns 2007;33:37–45. 41. Willebrand M, Andersson G, Kildal M, Ekselius L. Exploration of coping patterns in burned adults: cluster analysis of the coping with burns questionnaire (CBQ). Burns 2002;28:549–54. 42. Kildal M, Willebrand M, Andersson G, Gerdin B, Ekselius L. Coping strategies, injury characteristics and long-term outcome after burn injury. Injury 2005;36:511–8. 43. Kildal M, Willebrand M, Andersson G, Gerdin B, Ekselius L. Personality characteristics and perceived health problems after burn injury. J Burn Care Rehabil 2004;25:228–35. 44. Willebrand M, Andersson G, Kildal M, Gerdin B, Ekselius L. Injury-related fear-avoidance, neuroticism and burn-specific health. Burns 2006;32:408–15.
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45. Watkins PN, Cook EL, May SR, Ehleben CM. Psychological stages in adaptation following burn injury: a method for facilitating psychological recovery of burn victims. J Burn Care Rehabil 1988;9:376–84. 46. National Network for Burn Care. National burn care standards. NHS Specialised Services; 2013. 47. Pandya AA, Pounds-Cornish EK, Goutos I. Sexual function, relationships and fertility post burn–a UK wide survey. In: Kamolz LA, Andel H, editors. 15th European Burns Association Congress, Austria, Vienna; 2013, p. 124. 48. Annon JS. The PLISSIT Model: a proposed conceptual scheme for the behavioural treatment for sexual problems. J Sex Educ Ther 1976; 2:1–15. 49. Masters WH, Johnson VE. Human sexual inadequacy. London: Churchill; 1970. 50. Pereira C, Murphy K, Herndon D. Outcome measures in burn care. Is mortality dead? Burns 2004;30:761–71. 51. Fogel C. Lauver D. Sexual health promotion. Philadelphia: WB Saunders, 1990:1–40.
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Sexual Function Following Burn Injuries: Literature Review Atisha A. Pandya, BSc,* Helen A. Corkill, RN,† Ioannis Goutos, BSc (Hons), MBBS (Hons), FRCSEd (Plast)† Sexual function is a profound facet of the human personality. Burns due their sudden and devastating nature can have longstanding effects on intimate function by virtue of physical sequelae as well as alterations in body image and perceived desirability. A considerable number of patients encounter problems with intimate function in burns rehabilitation; nevertheless, the topic appears to be poorly addressed in specialist centers worldwide. Review of the literature suggests that a number of parameters can affect the quality of sexual life following burn injuries including age at the time of injury, location, and severity of the burn as well as coping mechanisms employed by the individual survivor. Addressing issues of intimacy relies on awareness, education, and a holistic approach on behalf of the multidisciplinary team members and, to this effect, recommendations are made on managing sexual function concerns in burns rehabilitation. (J Burn Care Res 2015;36:e283–e293)
Human sexual function has five discreet components, namely1, •• Sensuality (need to be conscious of and comfortable with own body through the five senses) •• Intimacy (need and ability to experience and enjoy emotional closeness with others and have this closeness reciprocated) •• Sexual identity (the individual’s sexual orientation, preferences, and gender roles) •• Sexualization (process of emphasizing the sexual nature of an individual), and •• Reproduction Burns are sudden and potentially life-changing injuries, which can have profound and long-lasting effects on the victim’s life. The consequences of a burn can be physical, imposing functional limitations, as well as psychosocial, affecting self-esteem and body image.2 From the *Kings College London Medical School, United Kingdom; and †Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Aylesbury, United Kingdom. Address correspondence to Ioannis Goutos, BSc(Hons), MBBS(Hons), FRCSEd(Plast), Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Mandeville Road, Aylesbury, Buckinghamshire HP21 8AL, United Kingdom. Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000196
Body image can be defined as the internalized mental picture of an individual’s physical appearance, which is influenced by perceived stereotypes of physical attractiveness, health, and function. This internalized mental picture is inseparable from sexuality, since the way in which a person perceives oneself has a huge impact on the way in which he/she partakes in intimate activities.3 Several studies have highlighted the strong link between a negative body image and low levels of sexual function in nonburn cohorts,4,5 and it therefore comes as no surprise that a number of reports in the burns literature support similar findings.6–9 Nevertheless, the subject has not attracted a lot of interest in the literature, and it appears that sexual function concerns postburn are not adequately addressed in specialist centres.10,11
METHODOLOGY The aim of this review is to examine all the existing knowledge on sexual function following burns. For the purpose of this work, the term sexual function is used in the widest sense to incorporate concepts including sexual esteem, desire, genital or nongenital intimate activity, as well as reproductive functions. We undertook an extensive English literature search using a number of databases: PubMed, ISI Web of Science, and CINAHL, and retrieved all articles pertinent to the topic to date. We present the various e283
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assessment tools employed to assess sexual function and analyze parameters affecting its quality following injury. We conclude by formulating recommendations for health professionals as to how best address these sensitive intimate issues in burns rehabilitation.
BURN INJURIES AND EFFECTS ON SEXUAL FUNCTION A variety of factors have been proposed in the literature as contributing to sexual dysfunction in burns patients and can be classified into the following major groups6: a) Psychopathological factors. Anxiety and posttraumatic stress disorder (PTSD) are common conditions affecting burn survivors and have a state of hyperarousal as a common denominator. The associated sympathetic overdrive has been found to affect the physiology of the sexual response by interfering with the arousal phase of the sexual response as well as the adrenergically mediated emission phase of orgasm.12 b) Psychodynamic factors. A fulfilling sexual life intimately links with a positive body image, which can be severely disturbed as a result of the injury and treatment received. In physical terms, burns involve a forceful change in appearance. Furthermore, the technical ward environment and specialist equipment employed for repeated medical/nursing procedures (involving exposed bodily parts) entails an element of dehumanization and redefinition of bodily boundaries. All of these factors have the potential to disturb the perception of body image and sexuality to a significant extent.7,13 Additionally, it is widely recognized that any significant physical trauma can result in psychodynamic regression. This state is highly reminiscent of “infantile dependence” and manifests itself with a demanding attention-seeking behavior, an apparent inability to make autonomous decisions as well as irrational childlike rejection of any sexualized thoughts or activities.14,15 c) Physiological aspects. Large burn injuries are associated with considerable hormonal imbalances, whose physiological effects can interfere with sexual function/reproduction. For example, the augmented release of stress hormones, including catecholamines and cortisol, interferes with sex hormone release leading to abnormalities of menstruation during rehabilitation.12 d) Medication side effects. Polypharmacy is common in burns rehabilitation and a large
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proportion of medications used ranging from antihypertensives (e.g., β-blockers) to psychotropic medications (e.g., antidepressant and anxiolytics) can interfere with sexual function. This occurs via a number of mechanisms including a central sedative action, the direct effect of drugs on peripheral neurotransmitters (α-adrenergic effect on erectile tissue), and hormonal imbalances (prolactin increase due to dopamine-blocking agents).6,16 e) Surgical issues. Burn injuries involving the external genitalia can have devastating effects on sexual function due to the damage to erectile and surrounding fascial tissues. The male reproductive organs are more prone to injury due to their external anatomical characteristics. Additionally, the physical morbidity from the surgical management of penile burns can be considerable; debridement with skin grafting can result in loss of the Dartos fascia, which normally provides an optimal gliding surface during sexual activity.8 f) Sensory issues. Wounds and scars can be accompanied by a number of significant sensory symptoms, including dysesthesia (altered sensation), hypoesthesia (lack of sensation/decreased sensation), and hyperesthesia (increased sensation). All of these can have a significant impact on intimate functioning, since tactile sensation is an integral component of sensual activity.17
TOOLS EMPLOYED IN THE ASSESSMENT OF SEXUAL FUNCTION POSTBURN There exist a limited number of literature reports appraising the quality of sexual function postburn. In broad terms, researchers have used varied methodology, which can be divided into marital satisfaction questionnaires, sexuality scales, and quality of life assessment tools.18–32
Marital Questionnaires Locke-Wallace Marital Adjustment Scale. This scale has been designed to determine marital satisfaction after injury or medical intervention. It comprises a 15-item questionnaire, which covers a number of aspects of married life including affection and sexual relations.18 Maudsley Marital Questionnaire. This comprises 20 Likert-scale questions, which evaluate three domains, namely marital (10 items), social (5 items), and sexual satisfaction (5 items). A low overall score indicates high marital satisfaction.19 Both of
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the above have been used in single burn literature reports, and their main limitation is that they apply to married individuals and hence may be considered out dated in an era of cohabitation rather than traditional marriage partnership status.
Sexuality Questionnaires Burn Sexuality Questionnaire (BSQ). The BSQ is a comprehensive 24-item assessment tool, which attempts to determine the degree to which a burn survivor is able to interact comfortably in terms of sex drive as well as sexual activity. Seven parts are purely demographic, and the remaining 17 cover multiple aspects of sexuality including domains of “body image,” “social comfort,” and “intimacy.” The BSQ has been reported to promote a good response from participants of a single study, who expressed appreciation at the topic of sexuality being addressed.20 This assessment tool has been recently translated to the Portuguese language21; nevertheless, it has not been widely adopted since it lacks validation as yet. Sexuality Scale (SS). This scale, originally developed in 1989 by Snell and Papini, evaluates three aspects of human sexuality, namely: sexual esteem (positive regard/confidence in the capacity to experience one’s sexuality in a satisfying way), sexual depression (experience of negative feelings regarding sex life), and sexual preoccupation (tendency to think about sex to an excessive degree).22 It has been found reliable and valid in predicting sexual behaviors in both sexes in nonburn cohorts23 and has been used in a single burn study of a male cohort.24 “What Young People Believe and Do” Questionnaire. This is an assessment tool used to assess sexual attitudes and behaviors in adolescents between 13 and 19 years of age.25 A shorter/revised version of it has been used in two burn studies appraising sexual attitudes in patients who sustained an injury during childhood/puberty.26,27 The main limitation of this tool is the restricted age range it applies to.
Quality of Life Assessment Tools Quality of Life Survey. A 9-point Likert scale is employed in this survey to allow individuals to rate their ideal versus actual sexual performance. The survey covers a wide variety of intimate aspects including sexual thoughts, nongenital intimate contact, as well as sexual intercourse and has been used in a single burn publication.28 Burn Specific Health Scale (BSHS). The BSHS is a 114-item outcome scale, which was subsequently abbreviated to 80 items, the Abbreviated Burn Specific Health Scale (BSHS-A). In this format, it
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assesses four aspects: physical, mental, social, and general, and these are further subdivided into eight domains, one of which is sexual activity. Despite being an abbreviated scale, the widespread use of the BSHS-A was still being hampered by its large size, and a further revision to a 31-item scale, the revised BSHS (BSHS-R) was produced. This scale contains seven domains, one of which is Interpersonal Relationships. However, this revised scale fails to encompass some relevant aspects of burn injury, and more specifically, items dealing with hand function and sexuality are excluded.29 The latest modification of the scale is in the form of the brief version (BSHS-B), which is a 40-item scale with nine domains which include interpersonal relationships and sexuality. The BSHS-B is described as a valid but shorter alternative to the BSHS-A and has been translated and validated in a variety of languages.30 Of the 40 questions, only three are directly related to sexuality, in particular the physical aspects of sex, namely: I feel frustrated because I cannot be sexually aroused as well as I used to be. I am simply not interested in sex anymore. I no longer hug, hold, or kiss. These questions although focusing on sexual activity, do so at a rather superficial level and are open to interpretation and therefore possible misunderstanding. For example, the statement “I no longer hug, hold, or kiss” does not specify whether it refers to sexual activity or social/familial interactions. Patients may be unsure how to answer the statements, and their ambiguity may result in some patients concerns about sexual matters not being fully highlighted. The BSHS-B, despite its limitations, is considered to be a valid and useful assessment tool for determining quality of life postburn and is indeed the most frequently used tool.9,17,31,32 It becomes apparent that a range of different assessment methods has been used in the burns literature to appraise levels and quality of sexual functioning following injury. Main limitations of the different tools relate to their applicability to certain age ranges and partnership status. Additionally, their lack of standardization and validity presents particular challenges in the study of sexual function.
FACTORS THAT PREDICT SEXUAL DYSFUNCTION A variety of factors appear to predispose to sexual dysfunction in burn injuries (Figure 1).
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Gender
Age at time of injury
Relationship status
Location of burn
Total burn surface area / depth
Coping mechanisms & personality Mechanism of injury
Figure 1. Patient- and injury-related parameters affecting the quality of sexual function following burn injuries. Background depicts Eros, red-figure bobbin, ca. 470 BC–450 BC, found in Athens. Original kept at the Louvre Museum, Department of Greek, Etruscan and Roman Antiquities, Sully wing, Campana Gallery (CA 1798), photographer: Jastrow (2006).
Gender The effect of gender on the quality of sexual function postburns is intriguing. A recent Australian study analyzed BSHS-B questionnaire responses in the sexuality and body image subdomains of 362 individuals (mean age: 39 years, mean TBSA of 10.7%, and TBSA range: 0.25–65%).17 Results suggest sexual arousal is affected to a similar extent in both males and females at 6 and 12 months postinjury. Loss of sexual interest at 12 months was more pronounced in females (12.3% males vs 31.8% females) as manifested by changes in hugging, holding, and kissing behavior. In terms of the body image/appearance domain, females reported more severe disturbances in body image across all stages of rehabilitation (1, 3, 6, 12 months) with especially significant changes at 12 months. The results from the study point toward females reporting greater levels of body image disturbances, and these potentially increase in severity over time during their rehabilitation. Similar results have been reached from a large study of 865 burn patients treated at the Royal Perth Hospital, with women scoring lower than men in the sexuality, body image, affect, and relationships domains32; this finding was more pronounced in major burn injuries.
A review of 54 patients in a U.S. center assessed postburn sexual function by asking patients to score their ideal versus actual performance in six different domains. A nine-point scale was employed based on the frequency of various intimate activities (including fantasies and intercourse) from 0 = not at all to 8= more than three times daily. Females expressed statistically significant lower levels of sexual satisfaction compared to males (52.6 vs 82.5%, P < .01), and this appears to strongly correlate with disturbances in body image.28 A prospective study in an Indian burn center involving 544 patients assessed quality of life using the Maudsley marital questionnaire 6 months postburn. The cohort comprised burn patients between 15 and 65 years in a stable married relationship with no preburn psychosexual disturbances. The control group consisted of 500 patients attending outpatient departments for nonburn-related conditions with the same inclusion criteria. A total of 52.94% of burn patients were found to be sexually dissatisfied, a result statistically significant in comparison to the control group (X2 = 117.8945; df = 1; twotailed P < .0001) with the majority of the dissatisfied patients being men (75.69%). Additional findings
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included the positive association between duration of hospital stay as well as between painful/unstable scars (P ≤ .0001) and penile deviation (P ≤ .0002) with sexual dissatisfaction. The authors attributed the gender difference in sexual dissatisfaction to societal/cultural attributes of masculocentricity. Men were deemed more vocal about their sexuality and open to discussions about postburn changes, whereas women were found to be reluctant to discuss their sexual lives and deemed to be more concerned about acceptance into society, child welfare, and household issues.19 The inference from the studies points toward their being a cultural filter in terms of reporting sexual dysfunction, with men in predominantly musculocentric cultures being more open toward sexual issues. Additionally, it is possible that, by virtue of their predominantly external nature, male genital organs are more prone to injury and the physical sequelae are reported more abundantly, whereas in females, issues of body image are more likely to be of prime concern depending on the nature of the tool employed to assess sexual function.
Age at Time of Injury Age at the time of injury is another interesting variable when examining factors that may predispose an individual to psychosexual problems. Evidence exists to indicate that patients with pediatric burns tend to have better adjustment/self-esteem and less sexual dysfunction than adult burn survivors.33,34 A study investigated sexual attitudes and behavior of 92 young adults burned (>30% TBSA) as children.26 The mean age at the time of the survey was 21 ± 2.7 years with burn injuries having occurred 14.2 ± 5.4 years earlier. The respondents completed the “What Young People Believe and Do” questionnaire, which consists of 76 questions relating to sexual knowledge, beliefs, behavior, and relationships. Patients were included if they were at least 2 years postburn and if the injury had occurred before the age of 18. The study hypothesis that individuals with burn scars have differences in sexual attitudes and limited sexual activity was disproved. The sexual attitudes and behaviors were comparable to the general population with the vast majority of respondents reporting significant sexual experience to suggest favorable psychosexual adjustment of children with major burns. A Finnish study of 91 patients, who sustained pediatric burns (90.1% scalds, mean TBSA 11.9%, median age of 1.4 years) has identified these injuries to be associated with transient long-term psychosexual
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sequelae, with 11 adult patients (20.8%) reporting difficulties in the commencement of sexual contacts at puberty. However, only one reported suffering sexual impediment later on in life.35 A comparative retrospective study in Texas examined the impact of scars on adolescent sexual development.27 Nineteen patients between 13 and 20 years (mean 12.23 years) at least 1 year following disfiguring burn injuries (TBSA range: 7–85%) completed a sexuality questionnaire (“What Would Young People Believe and Do,” revised). The results of the study were compared with reports on sexual beliefs and attitudes amongst the general adolescent population within the United States of America. The results indicated that those with disfiguring burn scars have thoughts, behaviors, and feelings that are similar to those of nonburned adolescents. They also indicated that the severity of disfigurement bore no correlation to the sexual behaviors of the teenagers, and additionally there was no correlation between burn severity and time of first intercourse or nongenital intimate touching. Interestingly, the study reports that 56% were thrilled with their first sexual experience compared to only 30% of the nonburned group. An Australian study using the Burn Specific Health Scale-Brief Version (BSHS-B) on 362 individuals found that the older the patient is at the time of injury, the greater the likelihood that he/she is to report some level of impact in sexuality-specific questions.17 Review of the relevant literature confirms that individuals burned during childhood/puberty appear to integrate successfully in terms of their sexual function.17,26,27,33–35 There are various hypotheses as to how this might occur including the fact that growing up with scars calls upon the individual to integrate their injury and physical sequelae within their identity as opposed to having to redefine their body/ sexual image in the context of a burn injury.36 Furthermore, if the burn injury precedes the very first sexual encounter, individuals have little to compare their first experiences to mentally or physically, and this may mediate better psychosexual adjustment.
Mechanism of Injury A study among 22 patients with electrical burns (at an average of 5.3 ± 4.9 years postinjury) using the BSHS-B revealed particularly low scores in the sexuality domain for patients with high-voltage burns (≥ 1000 V). Patients with large TBSA burns were found to score lower on the sexuality domain as well as body image. Impairments in sexual functioning
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as well as affect and work satisfaction appeared to persist at a substandard level over a long period of time (5 years).31 Contributory factors toward these findings include the well-described detrimental neuropsychiatric effects associated with electrical injuries (with depression being one of the commonest sequelae) as well as damage to nerves and blood vessels, which can lead to ischemia and pain especially in areas of erectile tissue.37
Burn Location and Scar Visibility The area of the burn appears to be a key element when looking at the risk factors involved in sexual dysfunction following burns.8,19,38 A small study of 10 patients (average TBSA 28%, mean age of 41) with penile burn injuries identified that these injuries contribute to considerable physical and psychological morbidity. Three out of 10 patients with skin grafts to the penis were disappointed with the functional results to the extent that two did not resume sexual activity at all and one resumed 12 months after injury. The latter patient, nevertheless, found his function unsatisfying despite normal apparent erectility. The effect of penile burns on sexual function in this study appears to relate not only to the functional effects of surgery/scarring but also to the lack of sex drive secondary to changes in body image.8 A prospective study by Ahmad et al investigated the factors that hamper the sexual life of 544 burn patients, who were in an ongoing relationship for at least a year prior to injury. The results show that pain over burnt genitalia or perineal regions during sex is one of the main issues amongst patients complaining of sexual dissatisfaction 6 months postburn. Additionally, a positive association between sexual dissatisfaction and penile deviation was identified (P ≤ .0002) in the cohort. Alongside the loss of libido, humiliation at exposure and dyspareunia were all very important factors also quoted as contributors to an unhappy sex life.19 Renshaw et al identified that burns on the inner thigh or near the scrotal area in men can lead to impairment of sexual function. In women, burns to the breast were considered to be mostly disfiguring amongst the victims, with lack of perceived attractiveness and poor self-confidence being important issues.38 These findings suggest that areas of burn close to the sexual organs but not involving the genitals themselves can have significant negative impact on a patient’s sex life. A closely related parameter associated with burn site is visibility of the resulting scarring, and it is
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interesting to investigate how it affects psychosexual behavior amongst burn survivors. A Finnish study of 91 patients who sustained pediatric burns identified that 20.8% of patients reporting difficulties in starting sexual contact at puberty had trunk scarring, and their sexual difficulties were not associated with scar visibility.35 This is not particularly surprising since it is known from other studies that hidden scars in children can lead to poor adjustment since individuals live with the fear of discovery and subsequent guilt. As a result, the whole process of body image revision is either delayed or remains incomplete.39 The effect of site visibility on sexual functioning may be different in adult burn victims. An Australian study found that in women there is a correlation between lower BSHS-B scores (body image and sexuality domains) and specific burn sites (limbs and face).32 This finding, which links sexual dysfunction to visible burned body parts, corroborates with results from other work suggesting that women’s reporting of sexual dysfunction relates predominantly to issues of body image.17 We propose that this may occur because females have to redefine their body image in the context of the increased cultural pressures to conform to beauty ideals, and hence it is not surprising that this is particularly challenging in the presence of visible scarring.
Burn Severity: TBSA and Depth A small study among 40 male burn survivors treated and discharged over an 11-year period in a Southeastern U.S. unit identified that there is no correlation between burn injury severity and sexual esteem/ depression and preoccupation.24 This initial finding was confirmed in a similarly small study of 54 patients, which showed no statistically significant differences in sexual satisfaction with respect to burn size.28 The first study suggesting a positive correlation between TBSA and worse sexuality score refers to a small group of 22 patients with high-voltage electrical burns (>1000 V). Patients with larger burns (>20% TBSA) had significantly lower sexuality scores than those with less extensive burns.31 Negative correlation has been identified in another report between sexual activity and percentage full thickness injury, the number of surgeries, as well as the length of hospital stay.40 A very recent study of 865 Western Australian patients found a positive association between decreasing scores for the sexuality domain of the BSHS-B and increases in TBSA in both male and female patients.32 The conclusion is that there appears to be an emerging strong link between TBSA and levels of sexual dysfunction.
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Coping Mechanisms/Personality Traits A variety of personality traits have been associated with sexual concerns/dysfunction. Patients with avoidant coping mechanisms (i.e., those who avoid contact with people/activities, are withdrawn/reluctant to change, and have restricted emotional expression) score significantly lower in the BSHS-B scale for the body image, affective, relationship, and sexuality domains compared to adaptive copers (outgoing attitude using emotional support and optimism as well as a hopeful approach to the future).41,42 Additionally, high levels of neuroticism have been linked with worse self-reported scores in the sexuality domain of the BSHS-B.43,44
Relationship Status The literature suggests that patients who are in a relationship prior to their injury score higher in the affect and relationship domains of the BSHS-B.32 Additionally, negative correlation has been found between sexual activity and living alone in a cohort of 95 patients, which studied self-reported sociodemographic factors and injury-specific factors determining long-term physical and psychosocial health.40
ADDRESSING SEXUAL DYSFUNCTION/RECOMMENDATIONS FOR BURN CARE PROFESSIONALS Issues surrounding sexual function are particularly delicate, and the way these are approached needs careful consideration. Important parameters in addressing sexual function issues relate to when, who, and how these issues are raised and managed. We review the current state of knowledge in the literature and propose recommendations for burn professionals.
When? The timing at which sexual issues in burns rehabilitation are broached and addressed is of vital importance. A seven-stage model for the psychological recovery of burns victims has been proposed by Watkins and is highly applicable to the exploration of issues surrounding sexual function.45 First stage: survival anxiety lasting for 1–2 weeks; the patients’ focus appears to be centered on evaluating the ability to survive the injury. Second stage: pain perception persisting for 6–8 weeks; this stage follows realization of the ability to survive the injury and centers on perceived pain and its relief. Third stage: search for meaning; patients search for an emotionally acceptable cause and effect rationale.
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Fourth stage: investment in recuperation; motivation and interest in self-care is typically heightened, and as individuals attempt more unassisted tasks, pride in self develops and verbalizes. Fifth stage: acceptance of losses; patients comprehend long-term losses as a result of the injury. Sixth stage: involvement in rehabilitation, which may take the form of further surgery which entail further reexamination and redefinition of self. Seventh stage: reintegration of identity through admission of losses and attempt to resume preburn functioning, through awareness directed at the differences between pre- and postburn experiences. The above model is key to allow burn professionals to gauge an appropriate time to introduce the sensitive topic of intimate function. Patients with big injuries undergo a prolonged period of physiological stabilization and hence are unlikely to be concerned with their sexual function until they reach the later stages of psychological adaptation (fourth stage— investment in recuperation). On the contrary, in patients with smaller injuries, the above model might not be as applicable (especially in terms of its timescale), and it may be appropriate to introduce the topic earlier on especially with injuries affecting erotogenous zones. In essence, healthcare professionals need to be aware that these issues may surface at different stages of rehabilitation and be prepared to act upon them with a positive, empathetic, and unbiased attitude.
Who? The question of who should be responsible for initially introducing the topic of sexuality in burns rehabilitation has been investigated in two literature reports. The first used a 28-item questionnaire completed by 71 North American burn care practitioners. Nearly half (47%) reported that there is no specific staff designated to discuss sexuality and intimacy, and 62% reported having received no specialized training on sexual topics in their units. Thirteen percent of the respondents believed it is solely the nurses’ responsibility to handle the issue with the majority agreeing that it should not be the patients who initiate such discussions. Only 14% of the burn practitioners in this study felt “very comfortable” to initiate such communications, and interestingly, the same percentage indicated satisfaction with the way their own body “looks and feels.”10 A Brazilian study employing the same methodology and questionnaire (completed by 120 practitioners from 41 centers) identified that only 28% of respondents were comfortable initiating discussions, with 34.7% indicating they were comfortable with
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their own body image and sexuality. The majority (76.6%) believed it to be the responsibility of the psychologist to discuss sexual and intimacy issues.11 It becomes apparent from these studies that there is marked hesitancy among healthcare professionals in initiating discussions pertaining to sexual health and function. This is not surprising given that different individuals have their own biases toward intimacy and many factors can contribute to discomfort in discussing sexual issues. These may include culture, religion, lack of training, age, as well as sexual orientation.10,11 Nevertheless, a reluctant attitude is likely to make burn patients feel disempowered to vocalize concerns independently, and it may contribute to the underreporting of this important subject in burn rehabilitation. Patients encounter many different members of the multidisciplinary team during their treatment timescale. Nursing staff might be in a particularly privileged position to broach and discuss the delicate subject of sexual function postburn. They are involved in round the clock care for the burns patient and consequently have the potential to develop a close trusting relationship, which is necessary to allow concerns to surface and be dealt with. Additionally, psychologists are equally empowered given their training to explore issues of sexual function with patients. In the United Kingdom, the National Network for Burn Care has recently outlined that all burn services should provide psychological care to burn-injured patients and their families as part of the National Burn Care Standards framework.46 The overwhelming majority of burn services in the United Kingdom currently offer routine psychosocial screening through dedicated psychologists; however, this does not routinely broach psychosexual topics.47 We believe that any willing, open-minded, and well-informed member of the multidisciplinary burn team could act as an important link toward identifying patients concerned about their sexual function and arrange appropriate follow-up with a professional (e.g., qualified sex therapist) according to the nature of the problem.
How? A particularly gentle way of introducing the concept that sexual function can be discussed openly in burns rehabilitation is by incorporating questions of sexuality in the initial assessment of patients’ admission for treatment. This approach obviously may not be appropriate in patients with very large or very small injuries. Therefore, professional discretion needs to
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be applied in this respect. Incorporating the topic within the initial encounter and obtaining a detailed sexual health history may go a long way in normalizing discussions of intimacy and “opening” the door to addressing specific concerns. Additionally, it allows the burns team to have a useful baseline for later sexual function assessments in rehabilitation. History taking should ideally use open (e.g. “tell me about your sexual activity”) as opposed to closed questions (i.e., “how often do you have sex normally”), since the latter have an element of assumptive disposition. Creating a relaxed private environment is crucial for these discussions; this can be accomplished by using a private therapy room and acknowledging the challenges involved in discussing intimate concerns. It is important to acknowledge that issues of sexual functioning may surface at any time during recovery and all involved disciplines need to be prepared to prompt, respond, and follow up appropriately. For example, the therapy outpatient setting may be appropriate to introduce/discuss this sensitive topic in a variety of ways as it relates to recovery from the physical effects of scarring. The PLISSIT model is a tool designed to assist healthcare professionals in discussing sexuality with patients. It takes its name from the four stages of Permission, Limited Information, Specific Suggestions, and Intensive Therapy.48 It is a model that appears to deal specifically with sexual concerns and, due to its flexible nonprescriptive nature, is easily adaptable to individual needs. The first stage, Permission, involves making patients and their partners aware of being able to ask questions and raise issues on matters of sexual behavior and intimate feelings. The second stage, Limited Information, involves giving the patient information that is applicable to their concerns in an anticipatory or direct question– answer format. In the third stage, Specific Suggestion, information is given to patients and their partners on behavioral changes that can help them to relieve anxiety and help generate patient/partner-derived solutions. This can be as simple as providing advice on how to protect graft sites during intercourse. The first three stages of the model allow intervention by nurses and other health professionals. The final stage, Intensive Therapy, involves referral to a sex therapist if the patients concerns have not been satisfactorily addressed in the first three stages. Whilst the PLISSIT model purports to need only the input of a trained sexual therapist in its final stage, the successful interpretation of the information
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derived from patients in its earlier stages and the subsequent advice that is given, requires training in sexual health, together with the confidence to address and successfully discuss such topics.48 This serves to highlight the importance of implementing training in sexual matters for staff members from each discipline and the need to increase awareness of this important subject matter so that the burns multidisciplinary team is able to respond to concerns appropriately.
Other Important Aspects of Psychosexual Care Medical/Surgical Treatment. Burn injuries involving erogenous zones need to be treated with particular care. Tissue-sparing approaches avoiding aggressive debridement of potentially viable tissue are indicated in an attempt to save as much erectile and fascial tissues as possible. Additionally, donor areas, when possible, should be planned in such a way as to avoid erogenous zones (e.g. inner thigh), given the effect they may have on intimate functioning by altering the tactile characteristics of the skin.38 Additionally, pharmacotherapy needs to be tailored to avoid a detrimental effect on sexual function (e.g., judicious use of agents with erectile side effects).6 Sensory Symptom Management. The effective treatment of unpleasant sensory symptoms (e.g., pain) in the initial stages of admission has been shown to be vital for the establishment of a trusting bond between staff and patients. Patients tend to perceive the provision of adequate analgesia indicative of staff concern for their welfare; hence, the best time to establish rapport and trust is during the first hours of a patient’s admission.7 This also applies throughout rehabilitation, where treatment of pain and itch should be a priority. Involvement of Partners. For burn patients in a relationship at the time of their injury, it is important to consider the involvement of their partner in psychosexual rehabilitation.19 Partners should be involved in discussions early on and become aware of the different stages that their “significant other” may go through during their recovery. These may include signs of withdrawal, avoidance, or irritability aimed at the partner. Furthermore, burns patients may use inappropriate or sexually overt comments and gestures toward their partner as a way of “testing of rejection.”7 It might also be prudent to encourage involvement of partners in skin contact. This can range from the use of simple touch during the rather
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“dehumanizing” critical care setting as well as during the scar rehabilitation phase. Moisturizing and massaging their partner’s scars can help both parties to overcome hesitant attitudes and the “fear of rejection,” by familiarizing individuals with the different feel and texture of the skin before discharge. Engagement of the partner in scar rehabilitation is likely to exert effects extending into the psychosexual sphere.3 Appropriate touching communicates involvement, reassurance, and affection and goes a long way to reestablish tactile relationships as well as allowing the integration of two diverse roles (caregiver and lover) to develop. The concept of engaging the partner in scar management derives from well-established practices of “Sensate Focus.” This encourages individuals to take pleasure in experiencing the texture and form of their partner’s body through touch with a view to helping build trust and intimacy in a relationship where negative reactions to intimacy and sex may have developed as a result of the burn injury.49 Grooming. Encouraging patients to pursue grooming activities is likely to be important in helping improve their sense of wellbeing and facilitate readjustments in body image.
DIRECTIONS FOR FURTHER RESEARCH Given the considerable advances in burn care, the survival rate of patients has increased over the past decades and patients’ resulting quality of life measures attain prominent focus. Traditional measures of outcomes including morbidity, mortality, and length of stay are being replaced by more holistic patient-reported measures that seek to capture the overall burn patient journey experience and assess the long-term effects of injuries.50 Given the vital importance of a healthy sexual life, the quality of intimate functioning needs to receive appropriate attention in assessing long-term outcomes. One of the main areas that need further research is the standardization of sexual function assessment postburn. A validated tool, which incorporates all aspects of sexual function and is applicable to a wide age range and partnership status, is eagerly awaited. Awareness of the need to be open about sexual function as part of burns rehabilitation is another area that needs further work, and this can only be achieved with educational programs for staff from all disciplines within the burn multidisciplinary team. This training should concentrate on establishing an adequate knowledge base and improving self-awareness of the personal value systems of burn services staff; these are
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essential prerequisites to enable staff to communicate genuinely and therapeutically with patients on sexual matters.51 The concept of establishing a “sexual health link” professional in burn services is an attractive concept. These individuals having undertaken appropriate psychosexual training could become designated members of staff in burns services, responsible for addressing patients’ sexual concerns in an effective and knowledgeable manner.
CONCLUSION Sexual function is an integral part of an individual’s life. Burn injuries by virtue of physical and psychosocial sequelae can have a profound impact on intimate functioning. A variety of patient- and injury-related parameters have been found to affect the quality of sexual life following burn injuries. Awareness of this important subject and specialist training for burn services staff is imperative to enable patients to express their sexual concerns and for these to be addressed in a professional manner. The successful achievement of these aims is likely to result in better psychosocial outcomes for the burn-injured patient. References 1. Shaniff E, Yahmina E, Munro B. Sexuality and disability: the role of health care professionals in providing options and alternatives for couples. Sex Disabil 2001;19:267–82. 2. Fobair P, Stewart SL, Chang S, D’Onofrio C, Banks PJ, Bloom JR. Body image and sexual problems in young women with breast cancer. Psychooncology 2006;15:579–94. 3. Bogaerts F, Boeckx W. Burns and sexuality. J Burn Care Rehabil 1992;13:39–43. 4. Ussher JM, Perz J, Gilbert E. Changes to sexual wellbeing and intimacy after breast cancer. Cancer Nurs 2012;35:456–65. 5. Tepper MS, Whipple B, Richards E, et al. Women with complete spinal chord injury: a phenomenological study of sexual experiences. J Sex Marital Ther 2001;27:615–23. 6. Dobkin de Rios M, Novac A, Achauer B. Sexual dysfunction and the patient with burns. J Burn Care Rehabil 1997;18:37–42. 7. Whitehead TL. Sexual health promotion of the patient with burns. J Burn Care Rehabil 1993;14(2 Pt 1):221–6. 8. Balakrishnan C, Imel LL. Effect of penile burns on sexual function. J Burn Care Rehabil 1995;16:508–10. 9. Elsherbiny OE, Salem MA, El-Sabbagh AH, Elhadidy MR, Eldeen SM. Quality of life of adult patients with severe burns. Burns 2011;37:776–89. 10. Rimmer RB, Rutter CE, Lessard CR, et al. Burn care professionals’ attitudes and practices regarding discussions of sexuality and intimacy with adult burn survivors. J Burn Care Res 2010;31:579–89. 11. Piccolo MS, Daher RP, Gragnani A, Ferreira LM. Sexuality after burn in Brazil: survey of burn health-care workers. Burns 2011;37:1411–8. 12. Axelrod J, Reisine TD. Stress hormones: their interaction and regulation. Science 1984;224:452–9. 13. McCloskey JC. How to make the most of body image theory in nursing practice. Nursing 1976;6:68–72.
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