Written by Provided By: Health Sciences Centre-Winnipeg; Manitoba Firefighters Burn Unit, JK3, 820 Sherbrook Street Winnipeg, MB R3A on October 28, 2019
Sexuality Issues for Adult Burn Survivors
Altered sensation
Physical pain, fragile skin and decreased mobility
Medication side effects
Altered body image; distraction with changes in the physical appearance
Partner’s discomfort with touching scars
Decrease in sexual activity related to sexual withdrawal, difficulty initiating sexual contacts, fear of rejection, social isolation due to lengthy healing time
Feeling sexually unattractive and lonely
Partner’s difficulty separating dual roles of caregiver and lover
Concerns with sexual health (menstruation, pregnancy, breastfeeding, erectile dysfunction)
Why is it Important to address sexuality with burn survivors?
One of the major consequences of a burn injury is the inevitable alteration in body image and subsequent challenge to one’s self-esteem. An individual’s expression of sexuality remains inseparable from body image and self-esteem. If sexuality is a part of a patient’s life, it must be considered along with other components of daily living. If patients do not return in some way to their pre-illness level of activities, they cannot be considered recovered or rehabilitated. Sexual information should be part of routine patient education.
“The patient did not mention it” is not an acceptable reason for not addressing sexuality. If sexuality is not addressed by the health care professional, it may suggest to the patient that this is not an appropriate topic of concern.
Patients often avoid discussion of sexual concerns with partners or members of the burn care team because of shyness, embarrassment, fear of rejection or the risk of seeming too occupied with thoughts of sexuality. Addressing sexuality directly grants the patient permission to be concerned about this sensitive issue. It can be an opportunity to remove the myths and mystery surrounding sexuality and clarifies misconceptions. It communicates to the patient and partner that sexuality is natural, normal and is potentially pleasurable.
Why do staff have difficulty addressing sexuality with patients?
Health care professionals may avoid discussing sexuality with patients for many reasons, such as anxiety in raising the topic, discomfort with their own attitudes, and a lack of knowledge. Staff may feel the patient will be uncomfortable during a sexual discussion or may feel the subject is an invasion of the patient’s privacy. Staff may also lack confidence in knowing the appropriate intervention.
The PLISSIT Model
The PLISSIT Model is a helpful tool to facilitate addressing sexuality with burn patients. Members of the burn team should be able to intervene at levels one, two and three.
P = Permission (level one)
Give the patient the permission to express sexual concerns. Many sexual problems can be solved by simply discussing sexual concerns and anxieties. Reassure them that their concerns are real and normal. Give out written material to go through with them or to follow up later.
LI = Limited Information (level two)
Provide the patient with factual information regarding the effect of burns on sexual functioning. Statistics on certain sexual practices let a patient know others share similar circumstances. Debunk myths, allay misconceptions and answer questions by providing accurate information.
SS = Specific Suggestion (level three)
Provide the patient with common sense observations, alternative methods of sexual expression and telling patients what other people have tried or found helpful.
IT = Intensive Therapy (level four)
Provide information for referral to sex therapists/counselors (see resource list).
Strategies for Addressing Sexuality with Patients
In order to feel comfortable discussing sexual issues with patients, you need to become knowledgeable of the potential sexual problems that burn patients may experience. Education regarding sexuality leads to a more accepting attitude.
A relaxed, private, environment is crucial. Put a “do not disturb” sign on the door if necessary. Good interpersonal skills such as good listening skills, a non-judgmental, accepting and empathetic attitude facilitates trust and communication. Acknowledge the challenge of the situation and reassure the patient that we are all sexual beings. Listen to the patient’s perceptions of what is happening and the difficulties encountered. Affirm the issues of sexuality during illness and the importance of it for overall health. Normalize the way the patient feels and let the patient know that his/her responses and concerns are the same as others in the same situation. Stress that they are not abnormal and that there are no dumb questions.
Appropriate timing to address intimacy and sexuality will vary for each patient, so keen observation and flexibility from the staff is a must. Generally, the handout, “Intimacy and Sexuality after a Burn Injury” should be provided as part of the discharge package.
In the acute stage of burn recovery, the patient is usually concerned with survival and sexual discussions may not be appropriate. The handout should be provided to the patient and reviewed along with the other discharge instruction sheets. Blending sexuality with other topics decreases discomfort for staff and the patient.
For example, when discussing hypertrophic scarring, you can discuss how changes in appearance affect body image, sometimes affecting sexual desire. Another example: “I am going to be talking to you a lot about your burn injuries. We also have information on sexual activity after a burn injury. If you ever have any questions feel free to ask”. This opens the door and lets the person know that this is a subject you are open to discussing.
It is the willingness of staff to address the issue of sexuality that empowers the clients to follow through with questions or comments. Refusal of the patient to talk about intimate matters must be accepted, but should always be readdressed in follow-up sessions. The patient may want to talk later.
Attempt to talk to couples together but do not assume how they identify sexually; use generic terms such as “your partner”. Also remember that sexuality is important whether or not the patient is in a relationship and should be addressed with everyone.
Additional Information to Consider
Patients with burns may be perceived as “untouchable” for fear of further injury or pain. Appropriate touch communicates affection, involvement and security to the burn patient, especially during the acute phase. Family members/partners should be encouraged to touch the patient’s unburned parts, and staff should take the time to touch the patient aside from painful procedures. An example of appropriate touch may be holding the hand or rubbing the feet.
The connection between body image as a part of grooming, style, and mobility is basic but is often neglected. Encourage the use of personal toiletries as soon as possible. Grooming may serve to improve overall sense of self worth, body image and attractiveness, for example, antiperspirant, hairstyle and cosmetics.
Burns involving the breast and/or genitals may carry special significance for the patient. For women, the breasts may represent femininity, symbolize motherhood and are associated with sensuality and sexual pleasure. Both genders may have concerns about fertility and functioning of sexual parts. Encourage the patient to discuss these concerns with their physician, and advocate referral to a specialist as necessary.
“Testing of rejection” by the burn patient is demonstrated by withdrawal avoidance and irritability aimed at the partner. If the partner is left unprepared and the patient remains unconscious of this phenomenon, confusion generates increased anxiety and withdrawal by each person. Testing of rejection is also evidenced by the use of inappropriate or sexually overt comments and gestures. Acknowledgment of these behaviors as inappropriate and the initiation of an assessment of underlying concerns is essential. Avoidance of this patient and these underlying concerns serves to communicate rejection.
Not having sufficient information may cause a couple to engage in activity before physical discomfort and psychological sensitivities have resolved. This may cause failure and disappointment and may start a vicious cycle.
Patients should be encouraged to attend burn support group meetings, talk with a peer supporter, borrow patient educational books and videos, be directed to appropriate websites and be referred to a sex counselor if appropriate.
References and Resources:
Annon, J. (1976). The PLISSIT Model: a proposed conceptual scheme for the behavioral treatment of sexual problems. Journal of Sexual Education Therapy, 2, 1-15.
Bogaerts, F., & Boeckx, W. (1992). Burns and sexuality. Journal of Burn Care & Rehabilitation, 13(1), 39- 43.
De Rios, M. D., Novac, A., Achauer, B. H. (1997). Sexual dysfunction and the patient with burns. Journal of Burn Care & Rehabilitation, 18(1 part 1), 37-42.
Fogel, C. (1990). Human sexuality and healthcare: sexual health promotion. In: C. Fogel & D. Lauver (Eds.), Sexual health promotion, (pp. 1-18). Philadelphia: WB Saunders.
Garts, K., & Garland, S. (1983). Marital satisfaction of the post-rehabilitation burn patient. Occupational Health Nursing, 31, 35-37.
Kalil, M. (2004, Fall). Facing motherhood: female burn survivors tell their stories.Burn Support News, 3, 1-3.
Kimmo, T., Jyrki, V., & Sirpa, A. S. (1998). Health status after recovery from burn injury. Burns, 24(4), 293-298.
Porcaro, D. (1988). Coping with sexuality problems I. In N. R. Bernstein, A. J. Breslau, & J. A. Graham (Eds.), Coping strategies for burn survivors and their families, (pp. 71-77). New York: Praeger Publishers.
Renshaw, D. C. (1989). Burn patients: emotional and sexual reactions. Medical Aspects of Human Sexuality, 23, 22-37.
Schover, L., & Fife, M. (1985). Sexual counselling of patients undergoing radical surgery for pelvic or genital cancer. Journal of Psychosocial Oncology, 3(3), 21-40.
Robert, R. S., Blakeney, P. E., Meyer, W. J. (1998). Impact of disfiguring burn scars on adolescent sexual development. Journal of Burn Care & Rehabilitation, 19(5), 430-435.
Roberts, F. (2003, Spring). Sexuality…the forgotten issue. Burn Support News, 1, 16-17.
Tudahl, L. A., Blades, B. C., Munster, A. M. (1987). Sexual satisfaction in burn patients. Journal of Burn Care & Rehabilitation, 8(4), 292-293.
Vecchiarelli, L. (1988). Coping with sexuality problems II. In N. R. Bernstein, A. J. Breslau, & J. A. Graham (Eds.), Coping strategies for burn survivors and their families, (pp. 79-84). New York: Praeger Publishers.
Whitehead, T. L. (1993). Sexual health promotion of the patient with burns. Journal of Burn Care & Rehabilitation, 14(2 part 1), 221-226.
Wilson, R. E. (1995). The nurse’s role in sexual counselling. Ostomy/wound management, 41(1), 72-4, 76, 78, 80, 82.
University of Iowa Health Care. Intimacy: Life after burns.Addressing sexuality with burn patients is challenging, but is extremely important. This handout is designed to provide staff with concrete suggestions on how to deal effectively with issues of sexuality and intimacy.
Sexuality Issues for Adult Burn Survivors
Altered sensation
Physical pain, fragile skin and decreased mobility
Medication side effects
Altered body image; distraction with changes in the physical appearance
Partner’s discomfort with touching scars
Decrease in sexual activity related to sexual withdrawal, difficulty initiating sexual contacts, fear of rejection, social isolation due to lengthy healing time
Feeling sexually unattractive and lonely
Partner’s difficulty separating dual roles of caregiver and lover
Concerns with sexual health (menstruation, pregnancy, breastfeeding, erectile dysfunction)
Why is it Important to Address Sexuality with Burn Survivors?
One of the most devastating consequences of a burn injury is the inevitable alteration in body image and subsequent challenge to one’s self-esteem. An individual’s expression of sexuality remains inseparable from body image and self-esteem. If sexuality is a part of a patient’s life, it must be considered along with other components of daily living. If patients do not return in some way to their pre-illness level of activities, they cannot be considered recovered or rehabilitated. Sexual information should be part of routine patient education.
“The patient did not mention it” is not an acceptable reason for not addressing sexuality. If sexuality is not addressed by the health care professional, it may suggest to the patient that this is not an appropriate topic of concern.
Patients often avoid discussion of sexual concerns with partners or members of the burn care team because of shyness, embarrassment, fear of rejection or the risk of seeming too occupied with thoughts of sexuality. Addressing sexuality directly grants the patient permission to be concerned about this sensitive issue. It can be an opportunity to remove the myths and mystery surrounding sexuality and clarifies misconceptions. It communicates to the patient and partner that sexuality is natural, normal and is potentially pleasurable.
Why Do Staff Have Difficulty Addressing Sexuality With Patients?
Health care professionals may avoid discussing sexuality with patients for many reasons, such as anxiety in raising the topic, discomfort with their own attitudes, and a lack of knowledge. Staff may feel the patient will be uncomfortable during a sexual discussion or may feel the subject is an invasion of the patient’s privacy. Staff may also lack confidence in knowing the appropriate intervention.
The PLISSIT Model
The PLISSIT Model is a helpful tool to facilitate addressing sexuality with burn patients. Members of the burn team should be able to intervene at levels one, two and three.
P = Permission (level one)
Give the patient the permission to express sexual concerns. Many sexual problems can be solved by simply discussing sexual concerns and anxieties. Reassure them that their concerns are real and normal. Give out written material to go through with them or to follow up later.
LI = Limited Information (level two)
Provide the patient with factual information regarding the effect of burns on sexual functioning. Statistics on certain sexual practices let a patient know others share similar circumstances. Debunk myths, allay misconceptions and answer questions by providing accurate information.
SS = Specific Suggestion (level three)
Provide the patient with common sense observations, alternative methods of sexual expression and telling patients what other people have tried or found helpful.
IT = Intensive Therapy (level four)
Provide information for referral to sex therapists/counselors (see resource list).
Strategies for Addressing Sexuality with Patients
In order to feel comfortable discussing sexual issues with patients, you need to become knowledgeable of the potential sexual problems that burn patients may experience. Education regarding sexuality leads to a more accepting attitude.
A relaxed, private, environment is crucial. Put a “do not disturb” sign on the door if necessary. Good interpersonal skills such as good listening skills, a non-judgmental, accepting and empathetic attitude facilitates trust and communication. Acknowledge the challenge of the situation and reassure the patient that we are all sexual beings. Listen to the patient’s perceptions of what is happening and the difficulties encountered. Affirm the issues of sexuality during illness and the importance of it for overall health. Normalize the way the patient feels and let the patient know that his/her responses and concerns are the same as others in the same situation. Stress that they are not abnormal and that there are no dumb questions.
Appropriate timing to address intimacy and sexuality will vary for each patient, so keen observation and flexibility from the staff is a must. Generally, the handout, “Intimacy and Sexuality after a Burn Injury” should be provided as part of the discharge package. In the acute stage of burn recovery, the patient is usually concerned with survival and sexual discussions may not be appropriate. The handout should be provided to the patient and reviewed along with the other discharge instruction sheets. Blending sexuality with other topics decreases discomfort for staff and the patient. For example, when discussing hypertrophic scarring, you can discuss how changes in appearance affect body image, sometimes affecting sexual desire. Another example: “I am going to be talking to you a lot about your burn injuries. We also have information on sexual activity after a burn injury. If you ever have any questions feel free to ask”. This opens the door and lets the person know that this is a subject you are open to discussing. It is the willingness of staff to address the issue of sexuality that empowers the clients to follow through with questions or comments. Refusal of the patient to talk about intimate matters must be accepted, but should always be readdressed in follow-up sessions. The patient may want to talk later.
Attempt to talk to couples together but do not assume heterosexuality; use generic terms such as “your partner”. Also remember that sexuality is important whether or not the patient is in a relationship and should be addressed with everyone.
Additional Information to Consider
Patients with burns may be perceived as “untouchable” for fear of further injury or pain. Appropriate touch communicates affection, involvement and security to the burn patient, especially during the acute phase. Family members/partners should be encouraged to touch the patient’s unburned parts, and staff should take the time to touch the patient aside from painful procedures. An example of appropriate touch may be holding the hand or rubbing the feet.
The connection between body image as a part of grooming, style, and mobility is basic but is often neglected. Encourage the use of personal toiletries as soon as possible. Grooming may serve to improve overall sense of self worth, body image and attractiveness, for example, antiperspirant, hairstyle and cosmetics.
Burns involving the breast and/or genitals may carry special significance for the patient. For women, the breasts may represent femininity, symbolize motherhood and are associated with sensuality and sexual pleasure. Both genders may have concerns about fertility and functioning of sexual parts. Encourage the patient to discuss these concerns with their physician, and advocate referral to a specialist as necessary.
“Testing of rejection” by the burn patient is demonstrated by withdrawal avoidance and irritability aimed at the partner. If the partner is left unprepared and the patient remains unconscious of this phenomenon, confusion generates increased anxiety and withdrawal by each person. Testing of rejection is also evidenced by the use of inappropriate or sexually overt comments and gestures. Acknowledgment of these behaviors as inappropriate and the initiation of an assessment of underlying concerns is essential. Avoidance of this patient and these underlying concerns serves to communicate rejection.
Not having sufficient information may cause a couple to engage in activity before physical discomfort and psychological sensitivities have resolved. This may cause failure and disappointment and may start a vicious cycle.
Patients should be encouraged to attend burn support group meetings, talk with a peer supporter, borrow patient educational books and videos, be directed to appropriate websites and be referred to a sex counselor if appropriate.
References and Resources:
Annon, J. (1976). The PLISSIT Model: a proposed conceptual scheme for the behavioral treatment of sexual problems. Journal of Sexual Education Therapy, 2, 1-15.
Bogaerts, F., & Boeckx, W. (1992). Burns and sexuality. Journal of Burn Care & Rehabilitation, 13(1), 39- 43.
De Rios, M. D., Novac, A., Achauer, B. H. (1997). Sexual dysfunction and the patient with burns. Journal of Burn Care & Rehabilitation, 18(1 part 1), 37-42.
Fogel, C. (1990). Human sexuality and healthcare: sexual health promotion. In: C. Fogel & D. Lauver (Eds.), Sexual health promotion, (pp. 1-18). Philadelphia: WB Saunders.
Garts, K., & Garland, S. (1983). Marital satisfaction of the post-rehabilitation burn patient. Occupational Health Nursing, 31, 35-37.
Kalil, M. (2004, Fall). Facing motherhood: female burn survivors tell their stories.Burn Support News, 3, 1-3.
Kimmo, T., Jyrki, V., & Sirpa, A. S. (1998). Health status after recovery from burn injury. Burns, 24(4), 293-298.
Porcaro, D. (1988). Coping with sexuality problems I. In N. R. Bernstein, A. J. Breslau, & J. A. Graham (Eds.), Coping strategies for burn survivors and their families, (pp. 71-77). New York: Praeger Publishers.
Renshaw, D. C. (1989). Burn patients: emotional and sexual reactions. Medical Aspects of Human Sexuality, 23, 22-37.
Schover, L., & Fife, M. (1985). Sexual counselling of patients undergoing radical surgery for pelvic or genital cancer. Journal of Psychosocial Oncology, 3(3), 21-40.
Robert, R. S., Blakeney, P. E., Meyer, W. J. (1998). Impact of disfiguring burn scars on adolescent sexual development. Journal of Burn Care & Rehabilitation, 19(5), 430-435.
Roberts, F. (2003, Spring). Sexuality…the forgotten issue. Burn Support News, 1, 16-17.
Tudahl, L. A., Blades, B. C., Munster, A. M. (1987). Sexual satisfaction in burn patients. Journal of Burn Care & Rehabilitation, 8(4), 292-293.
Vecchiarelli, L. (1988). Coping with sexuality problems II. In N. R. Bernstein, A. J. Breslau, & J. A. Graham (Eds.), Coping strategies for burn survivors and their families, (pp. 79-84). New York: Praeger Publishers.
Whitehead, T. L. (1993). Sexual health promotion of the patient with burns. Journal of Burn Care & Rehabilitation, 14(2 part 1), 221-226.
Wilson, R. E. (1995). The nurse’s role in sexual counselling. Ostomy/wound management, 41(1), 72-4, 76, 78, 80, 82.
University of Iowa Health Care. Intimacy: Life after burns.