Addressing sexuality in dermatologic

Addressing sexuality in dermatologic nursing care

Sexuality is a basic human need. However, sexuality is not always included in the nursing assessment. Studies have uncovered barriers that give us insights into how we can improve our clinical practice and assess sexuality more frequently with our patients. How can we assess sexuality by increasing our knowledge? And how do we promote a positive attitude toward sexuality, combined with standardized use of the “Dermatology Life Quality Index”?

ASTRID BLIKSTAD is Clinical Nurse Educator at Ward of Dermatology, Oslo University Hospital and senior advisor for The Norwegian Psoriasis and Eczema Association (PEF).

Sexuality is a basic human need. It’s a part of our primal instincts. Its biological complexity makes us able to survive and reproduce as a species. We all know that sex is fun, too – alone or with others – regardless of our socio-cultural norms that have tried to keep this fact a well-kept secret, especially for gay and female sexuality.

Understanding what the term sexuality means is important. Sexuality is sex, health, gender identity, sexual orientation, fantasies, intimacy, reproduction, pleasure, identity and so much more. Just as important is to understand our own attitudes toward sexuality. As for many other aspects of our profession, it is important that we explore our own values, beliefs and disbeliefs, insecurities, and prejudices.

Addressing impaired sexuality

Clinical studies recognize that people living with different skin diseases are at risk of impaired sexuality.1 This issue should be addressed at an equal level with other kinds of treatment in a healthcare setting. However, studies have uncovered barriers, which include lack of knowledge, taboos, fear of negative feedback and the lack of clinical practice guidelines.2 Having uncovered these barriers also provides us with knowledge about how we can improve our clinical practice and assess sexuality more frequently with our patients.

We can self-reflect, and we can reflect upon our practise together with our colleagues. Selfreflection is, in my mind, a key to increase our communicative skills. This is important, and ideally, we should also create a safe and positive work environment where we can discuss sexual health topics and promote professional development in our field of nursing.

Ask the question: “How do we assess sexuality in my workplace?” If you don’t have an answer, find out why.

A holistic understanding of sexuality

As nurses, we can analyse disease impact on sexuality in two assessment/intervention domains – both the direct impact and indirect impact of sexuality. A direct impact would be

A systematic assessment of the patient’s sexual health status gives us the opportunity to support sexuality by normalizing, providing information, and facilitating positive coping strategies.

physical changes causing a form of sexual impairment. And indirect would be the psycho-social: : self-esteem, body image, shame, stigma, or identity changes.

Assessing and addressing sexuality in a holistic and positive approach can give us the opportunity to facilitate our patient’s exploration of sexuality – what it means for them. Sexuality is not only sexual activities like masturbation or intercourse. It’s a very subjective experience and includes kissing, hugging, cuddling, and other forms of intimacy.

Disease manifestations affecting sexuality

We all know that the skin is a huge sensory organ as well as providing other vital functions of the skin. If we didn’t have skin, we would all be dead, and we would look horrible with our leaking bodies, with muscles and tendons hanging out on display – which would not matter because we would all be dead. But back to the sensory function. We communicate with our environment through touch, and socially with our skin itself. So how can a skin disease affect our sexuality?

A direct impact can be exemplified with inverse psoriasis where the genitals may be directly affected by the disease and hence make it painful to masturbate or have intercourse. For people with hidradenitis suppurativa, painful boils, wounds, and fistulas with secretion in the genital region make wanting or having sexual activities problematic. The same thing is the case for people living with other skin diseases that affect the genitals directly like lichen sclerosis or genital ulcers.

Indirectly, a skin disease regardless of whether occurring on the genitals or on other parts of the body can induce low self-esteem, altered body image, and self-perceived stigma, among other psychosocial factors.4 Itching is a common symptom that can affect the feeling of pleasure or the surplus energy to have sexual play. Psychological diseases such as anxiety and depression also play a role in an individual’s sexual health, and we now know that several chronic skin diseases are linked to an increased risk of mental health issues.3

DLQI in a multidisciplinary approach

In a variety of diagnoses, from cancer to bowel disease, nurses and health personnel describe in the literature barriers to why sexuality or sexual health is not always so well communicated between health personnel and their patients.2 Some of these barriers are lack of knowledge, embarrassment or taboo, fear of negative feedback, lack of angle or motive to initiate the talk, lack of time and suitable environment, or lack of procedures and routines. To facilitate the assessment of sexual function in a dermatological setting, the idea is to standardize the use of the Dermatology Life Quality Index (DLQI) questionnaire. All adult patients can receive the questionnaire when admitted to the dermatological ward. Nurses can

CONCLUSION: We can inform, guide, and help the patient to adopt positive coping strategies, and normalize sexual challenges. Skin disease or not, many of us cherish our looks as a central aspect of our sense of sexuality. Not all patients want to talk about their sexuality and that’s fine! However, we can open the door. Using the DLQI questionnaire in a multidisciplinary approach may help meet the patient’s needs and raise awareness of sexual health in dermatology.

use the DLQI in the nursing assessment, and the form provides information about the patient’s Quality of Living (QoL) including sexuality. Especially questions 2, 8, and 9 address this issue.

Question 2 investigates perceived embarrassment or self-consciousness, which may relate to the experience of stigma or shame from having the skin disease. Questions 8 and 9 address perceived problems with a partner and/or problems with friends and sexual difficulties.5 The qualitative and quantitative properties of the questionnaire are important for both the dermatological nurse and the dermatologist.

A systematic assessment of the patient’s sexual health status gives us the opportunity to support sexuality by normalizing, providing information, and facilitating positive coping strategies. In our experience, it may accelerate referral to other types of health personnel who may be a support to our patients, such as a psychiatric nurse or a social worker.

A key aspect is to talk through the form together with the patient after documenting the score of the DLQI questionnaire.

After handing out and collecting the form routinely at admission, collect the score and document it. Then give, let’s say a 15-minute timeframe. You can say to the patient: “I have 15 minutes. I want to hear more about your quality of life, including your sexual life”. In this way, you have a natural way of assessing sexuality and QoL in a fair timeframe.

This article is based on my manuscript from the talk “Addressing sexuality in dermatologic nursing care” in nurse session 2 at the 35th NCDV 2022 in Copenhagen Friday April 22.

References:

1. Sampogna F, Abeni D, Gieler U, et al. Impairment of Sexual Life in 3,485 Dermatological Outpatients from a Multicentre Study in 13 European Countries. Acta Dermatovenereologica. 2017;97(4): 478-482. 2. Blikstad A, Falch- Koslung L,Tschudi-Madsen C. Samtaleverktøyet BETTER kan gjøre det lettere å snakke om seksualitet. (2020). Oslo: Sykepleien.no. 3. Dalgard F, Gieler U, Tomas- Aragones L. et al. The Psychological Burden of Skin Diseases: A Cross-Sectional Multicenter Study among Dermatological Out-Patients in 13 European Countries. J Invest Dermatol. 2015 Apr;135(4): 984-991. 4. Barisone M, Bagnasco A, Hayter M, et al. Dermatological diseases, sexuality and intimate relationships: A qualitative meta-synthesis. J Clin Nurs. 2020;29(17-18): 3136-3153. 5. Finlay, A Y, Khan G K. Dermatology Life Quality Index (DLQI)--a simple practical measure for routine clinical use.” Clin exp dermatolvol. 1994 May;19(3): 210-6.

CONFLICT OF INTEREST: The Norwegian Psoriasis and Eczema Association (PEF) collaborates with LMI.