Recommendations on Sexuality and Intimacy After Burn Injuries

Response (with indications of the change made in the manuscript, all references to pages and lines are related to the resubmitted manuscript)

Reviewer 1

Very nice and important paper. The only correction I would recommend is the comment about those burned as children not having sexual dissatisfaction or body image issues - line 195 & 196. (Ref #15.) There is only one reference and this is a bold statement. It certainly has not been substantiated by any of the many studies and retreats with sexuality discussions that I have had with numerous burn children and adolecents and those adults burned as children, especially females. I would recommend that this statement be elminated.

We thank the reviewer for these positive comments. We removed the sentence about children or adolescents not having sexual dissatisfaction or body image issues and removed the references and changed references list accordingly.

Reviewer comment      

Response (with indications of the change made in the manuscript, all references to pages and lines are related to the resubmitted manuscript)

Reviewer 2

As a burn researcher from Asia, I believe this research is highly necessary. In our actual clinical practice, it is indeed very difficult to discuss sexual issues with patients. This research, from a multi-disciplinary perspective, provides clear guidance from both the patient's and medical staff's viewpoints. The research process demonstrates rigor and scientificity, and the writing level is also very high. I suggest this article be published.

We thank the reviewer for these positive comments and appreciate that the reviewers agrees with the importance of the paper.

Reviewer comment

Response (with indications of the change made in the manuscript, all references to pages and lines are related to the resubmitted manuscript)

Reviewer 3

This manuscript very interesting because no too much manuscripts and abstracts about Sexuality.

We appreciate that the reviewers agrees with the importance of the paper.

Major points:

1.           In the "Materials and methods", there are not descriptions as for age, sex of the patients. What total body surface area (TBSA) burnt and depth of burns and how many days the patients treated in the hospital.

2.           How many patients included.

3.           post-burn complications (scars, contractures)

4.           Did the interdisciplinary expert group include a combustion specialist and psychiatrist?

5.           Did the physical therapist prescribe any exercises after treatment?

Thank you for this comment and for the opportunity to clarify our study design. Considering points 1, 2 and 3:

This study was not an intervention study nor a clinical observational study involving patient-level data. As outlined in the Materials and Methods section, the manuscript describes the development and validation process of educational and communication tools, informed by a narrative literature review, expert clinical consensus, and iterative qualitative feedback from patients and healthcare professionals.

No individual-level clinical data were collected, recorded, or analysed. Consequently, variables such as age, sex, TBSA, burn depth, length of hospital stay, number of patients, or post-burn complications (e.g. scars, contractures) were not within the scope of this study and are therefore not available to report.

Patient involvement occurred exclusively in the form of qualitative feedback sessions and round-table discussions, with patient representatives at various stages of recovery contributing reflections on usability, relevance, clarity, emotional resonance, and cultural appropriateness of the tools. These contributors were not study participants in a clinical or epidemiological sense, and no attempt was made to characterise or stratify them using medical variables.

To avoid further misunderstanding, we have clarified the non-interventional, qualitative nature of the study in the Materials and Methods section in line 159-161 explicitly stating that no patient-level clinical characteristics were collected or analysed.

4. The expert group did not include a combustion specialist nor a psychiatrist.

5. This study was not an intervention study so the physical therapist did not perform any exercises. We hope these clarifications addresses the reviewer’s concern.

Physiological factors

Could you please be more specific?

Thank you for this suggestion. We agree that further clarification can strengthen this section. In the revised manuscript, we have expanded the description of physiological factors to more explicitly describe the underlying mechanisms by which burn injury and its treatment can affect sexual function. Specifically, we now elaborate on the role of the acute and chronic stress response, burn-related endocrine dysregulation, medication effects, and vascular and neurological sequelae, which together may contribute to reduced libido, arousal difficulties, fatigue, and erectile dysfunction in line 238-248. This additional detail enhances clarity while remaining consistent with the narrative and integrative nature of the review.

Relational and Communication Barriers

Add more specific

We appreciate this comment and agree that greater specificity improves clinical relevance. We have expanded this subsection to more concretely describe commonly reported relational challenges, including changes in partner dynamics, fear of rejection, altered roles during recovery, avoidance of intimacy, and uncertainty regarding how and when to resume sexual activity. Additionally, we now more explicitly describe communication barriers within healthcare encounters, such as lack of clinician training, assumptions about asexuality after trauma, and time or role constraints, which can prevent sexual health concerns from being addressed proactively; line 265-277. These additions aim to provide clearer guidance for clinicians while remaining grounded in the existing literature.