3. Sexual History Taking

Sexual History Taking

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Many healthcare professionals feel concerned about their ability to take an appropriate sexual history, however skilled and confident they may be at taking a standard history. In part, this is a reflection of educational practices - sexual history taking has tended to be taught separately - but also is testimony to the social embarrassment and difficulties we experience talking about sex in general. With appropriate training and experience, this can be conquered. For some patients, there may be great discomfort, trepidation and even shame felt approaching a medical professional for help in sexual matters.

Why should we ask?[1]
  • Prevention of morbidity and mortality associated with sexually transmitted infection (STI). For example:
    • Earlier identification and treatment of STIs such as chlamydia or HIV.
    • Increased opportunities for preventative care, e.g hepatitis B immunisation, discussion regarding sexual risk-taking.
  • Identifying sexual dysfunction:
    • High prevalence in the general population - most often undiagnosed and untreated.
    • As a marker of organic or psychiatric disease, eg erectile dysfunction (ED) as a risk marker for cardiovascular disease (CVD).
    • As an iatrogenic side-effect of medication or surgery.
  • Association of sexual health with a current problem, eg anxiety or depression related to a history of sexual abuse.
  • Sexuality and sexual function are integral aspects of an individual throughout life. Sexual health is associated with happiness, longevity and wellbeing. We increasingly recognise the importance of sex to many of our elderly patients and those with chronic illness or disability, as well as the young and fit.[2]

Most primary care physicians in one American study were comfortable taking a sexual history when they perceived the presenting complaint as directly relating to a sexual problem; however, many fewer used sexual history-taking skills in a more proactive way, as part of routine and preventative healthcare.[3]

Privacy

  • The physical environment should be welcoming and comfortable but consultations should take place in private and behind sound-proofed doors.
  • Partners or relatives may prevent a patient from revealing personal information - ideally, see patients alone.

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Confidentiality

  • Patients should be assured of confidentiality - all NHS employees should adhere to the Caldicott principles for confidentiality and the General Medical Council (GMC) has specific guidance.[4]
  • The duty of confidentiality can only be broken in exceptional circumstances when it is in the patient's or public's interest - for example, certain child protection cases.
  • Duty of confidentiality should be explained to the patient verbally but also reflected in patient literature, posters, etc.

Permission and explanation

  • Only ask for the information that you need to manage the patient correctly. Avoid intrusive and unnecessary questions.
  • If the patient has not come with a complaint directly related to sex, check that they are happy to discuss sexual concerns with you, either now or in the future.
  • Questions should be asked in a matter-of-fact, yet sensitive, way. Start with the least intrusive questions before asking ones that are potentially more embarrassing.
  • Explain why you need to ask the questions, eg to assess the risk of STIs and to enable you to know which sites to take swabs from.

Communication skills

  • Patients are often vague or use euphemisms if embarrassed. Listen and watch to ensure you have understood and whether you need to ask further questions to confirm. Use open questions to initiate the consultation, clarifying with closed questions if required.
  • Non-verbal cues are particularly important.
  • Do not make assumptions, and use neutral terms such as 'person' or 'partner' (rather than 'boy/girlfriend', 'wife/husband') until you have confirmed an individual's sexual orientation and relationship status. Do not ask whether individuals are married or monogamous; rather, ask how many partners they have had.
  • If discussing sexual behaviours, ensure that the patient understands any medical terminology you may use and that you understand their slang terms. Some patients prefer doctors to use colloquial terms to discuss sex; others would find this off-putting.

Attitudes

Human sexual behaviour is diverse. Health professionals should avoid moral or religious judgement of their patient's behaviour, as has happened in the past. Concentrate instead on managing health-related needs, including psychological and emotional, and take time to address the patient's concerns.

Core sexual history components based on British Association for Sexual Health and HIV (BASHH) Guidelines:[5]
  • Reasons for attendance.
  • Symptom review.
  • Last sexual intercourse (LSI) - date, patient gender, sites of exposure, condom use.
  • Previous sexual partners - as for LSI.
  • Previous STIs.
  • For women - last menstrual period (LMP), contraceptive and cytological history.
  • HIV, hepatitis B and hepatitis C risk assessment.
  • Establish mode of giving results.
  • Establish competency/child protection concerns if aged under 16 years.

Taking a sexual history in general practice may be rather different; direct seeking of sexual health advice in relation to a specific symptom is less common. More sexual health work is opportunistic or in response to detecting a 'hidden agenda'. Time constraints are great but the ability to develop an ongoing and trusted relationship with a patient means that they may return in the future if we give opportunity and signals that we are happy to discuss sexual matters.

Presenting complaint

Check the patient's reason for attending. They may require advice or a check-up or they may have a specific symptom. Where symptomatic, check the duration and nature of any reported symptoms.

Symptom review

Many clinicians in a genitourinary medicine (GUM) clinic or in general practice where a patient is reporting a sexual health-related problem, may routinely ask about specific symptoms.
In women:

  • Change in vaginal discharge.
  • Vulval skin problems.
  • Lower abdominal pain.
  • Dysuria.
  • Changes in menstrual cycle or irregular bleeding.

In men:

  • Urethral discharge.
  • Dysuria.
  • Genital skin problems.
  • Peri-anal/anal symptoms.

History of the presenting complaint

Partners

  • Are they sexually active?
    • Sexual history should cover all partners within the preceding 3 months.
    • If no partners are reported during this time, then the last time the patient was sexually active should be noted.
    • If the patient is symptomatic, the sexual history should cover all partners during the incubation period of STIs that may cause current symptoms.
    • Where no unprotected penetrative oral, vaginal or anal sex is reported during this period, ask when the last time was that this took place.[5]
  • Check the relationship of symptoms to LSI or to intercourse with a particular partner.
  • Condom use - determine whether always, sometimes or never.
  • Type of sex - eg oral, vaginal, anal.
  • Symptoms or diagnosis of partner(s).
  • Sex with same or opposite sex partners - check directly: "Have you ever had sex with another man?"
  • Sex work - check: "Have you ever been paid for sex?"
  • Partners from overseas in the preceding year.

Menstrual history and contraception

  • Check if contraception has been used and, if so, what method.
  • Check correct usage.
  • LMP/LSI in relation to cycle/possibility of pregnancy.
  • Menstrual abnormalities (intermenstrual or postcoital bleeding).

Previous STIs

  • Previous diagnoses (and dates).
  • Treatment.
  • Compliance.
  • Treatment of partner (consider risk of re-infection).

Psychosexual

Where a sexual 'problem' or dysfunction has been identified, ask:[6]

  • How the patient sees the problem and what they consider the cause to be.
  • The duration of the problem and whether it is related to the time, place or partner.
  • Loss of sex drive or dislike of sexual contact.
  • Sources of stress, anxiety, guilt or anger.
  • Any physical problems, eg pain.
  • Carefully exclude illnesses that may affect sexual performance, eg CVD, testosterone or thyroid deficiency, pelvic or spinal trauma/surgery, arthritis.

In addition:

  • Past medical and surgical history.
  • Current medication, including over-the-counter and recreational drugs.
  • Allergies.
  • Smoking and alcohol use.
  • Intravenous drug use with needle sharing (ever), and last use.
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Further reading & references

  1. Nusbaum MR, Hamilton CD; The proactive sexual health history. Am Fam Physician. 2002 Nov 1;66(9):1705-12.
  2. Kleinplatz PJ; Sexuality and older people. BMJ. 2008 Jul 8;337:a239. doi: 10.1136/bmj.a239.
  3. Wimberly YH, Hogben M, Moore-Ruffin J, et al; Sexual history-taking among primary care physicians. J Natl Med Assoc. 2006 Dec;98(12):1924-9.
  4. Confidentiality, General Medical Council, 2009
  5. UK National guidelines on undertaking consultations requiring sexual history taking, British Association for Sexual Health and HIV (2006)
  6. Tomlinson J; ABC of sexual health: taking a sexual history. BMJ. 1998 Dec 5;317(7172):1573-6.
Original Author: Dr Chloe Borton Current Version:
Last Checked: 20/04/2011 Document ID: 8997  Version: 2 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.