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.

General pointers

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.

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, e.g. 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.

Taking a sexual history

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 - e.g. 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, e.g. pain.
• Carefully exclude illnesses that may affect sexual performance, e.g. 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.

Document references

1. Nusbaum MR, Hamilton CD; The proactive sexual health history. Am Fam Physician. 2002 Nov 1;66(9):1705-12. [abstract]
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. [abstract]
4. Confidentiality, General Medical Council, 2009
5. French P; BASHH 2006 National Guidelines--consultations requiring sexual history-taking. Int J STD AIDS. 2007 Jan;18(1):17-22.
6. Tomlinson J; ABC of sexual health: taking a sexual history. BMJ. 1998 Dec 5;317(7172):1573-6.

Acknowledgements