Sexual history taking

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. Healthcare professionals may feel comfortable taking a sexual history when they perceive the presenting complaint as directly relating to a sexual problem; however, use of sexual history taking in a more proactive way, as part of routine and preventative healthcare, may be more difficult. With appropriate training and experience, these difficulties 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 about sexual history?

• Prevention of morbidity and mortality associated with sexually transmitted infection (STI). There is evidence that sexual risk-reduction counselling in primary care is effective in preventing STIs.¹
  

  • Earlier identification and treatment of STIs such as chlamydia or HIV.

  • Increased opportunities for preventative care - eg, hepatitis B immunisation, discussion regarding sexual risk-taking.

• Identifying sexual dysfunction:
  

  • High prevalence in the general population - most often undiagnosed and untreated.^{2 3}

  • 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 or to sexual difficulties within a relationship.

• Sexuality and sexual function are integral aspects of an individual throughout life. Sexual health is associated with happiness, longevity and well-being. 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.^{4 5}

General pointers⁶

Privacy

• The physical environment should be welcoming and comfortable but consultations should take place in private and behind soundproofed 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.⁷

• The duty of confidentiality can only be broken in exceptional circumstances when it is in the patient's or the public's interest - for example in certain child protection cases, where the risks to society from a communicable disease outweigh the confidentiality of the patient or to protect from serious harm due to crime.

• The duty of confidentiality and its limits should be explained to the patient verbally but also reflected in patient literature, posters, etc.

• In specialist clinics for treatment of STIs, legislation protects additional confidentiality. In these settings, it is not routine to inform the GP of results but it is good practice to request permission to do so if there are other health implications.

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. If the doctor appears to be embarrassed then the patient will be too. 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.

• A chaperone should always be offered for intimate examinations.

• Literature advertising or explaining sexual health clinics should explain the need to take an appropriate sexual history, so that people are forewarned.

Communication skills

• Appropriate greeting and maintaining eye contact (if culturally acceptable) are crucial.

• 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; use neutral terms such as 'person' or 'partner' (rather than 'boy/girlfriend', 'wife/husband') until you have confirmed an individual's sexual orientation, gender 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.

• There should be capacity to accommodate and communicate with those whose first language is not English, using official interpreters (in person or on the phone) rather than friends or family. Provision must also be made for those who need a sign-language interpreter.

• Ensure that any patient who presents with a partner is also seen alone, in case there is any controlling behaviour from the partner which would stop them from speaking freely. Some clinics have innovative ways for patients to indicate this - for example, two colours of pen in the toilet. If the sample is named in red rather than black, the staff will know that the patient wants to discuss problems in the relationship/abuse.

Attitudes

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

Requests for a clinician of a particular sex on cultural or religious grounds, or due to personal preference, should be accommodated where possible.

Taking a sexual history⁶

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.

• Testicular swellings or discomfort.

• Peri-anal/anal symptoms.

Partners

• Establish if the person is sexually active
  

  • Sexual history should cover all partners within the preceding three 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.

  • Establish relationship with partner (eg, live-in, casual, paid) in order to assess risk and to facilitate partner notification.

  • Where no unprotected penetrative oral, vaginal or anal sex is reported during this period, ask when the last time was that this took place.

• Check the relationship of symptoms to LSC 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 - if a long-acting method such as the implant has been inserted recently, is there any possibility that the patient may have been in early pregnancy at the time of insertion and if so has a pregnancy test been done at least three weeks after insertion?

• LMP/LSC in relation to cycle - establish if there is possibility of pregnancy.

• Menstrual abnormalities (intermenstrual or postcoital bleeding).

Previous STIs

• Previous diagnoses (and dates).

• Treatment.

• Adherence.

• Treatment of partner (consider risk of re-infection).

Psychosexual history

Where a sexual 'problem' or dysfunction has been identified:

• Establish how the patient sees the problem and what they consider the cause to be.

• Determine the duration of the problem and whether it is related to the time, place or partner.

• Ask about loss of libido or dislike of sexual contact.

• Explore sources of stress, anxiety, guilt or anger.

• Ask about physical problems - eg, pain.

• Carefully exclude illnesses that may affect sexual performance - eg, CVD, testosterone or thyroid deficiency, pelvic or spinal trauma/surgery, arthritis.

• Explore the possibility of sexual abuse.

In addition

• Past medical and surgical history.

• Current medication, including over-the-counter and recreational drugs.

• Allergies.

• Human papillomavirus (HPV) vaccination history in women born after 1995 or those eligible in adulthood - eg, men who have sex with men, and people living with HIV.

• History of cervical cytology in women.

• Smoking and alcohol use.

• Intravenous drug use with needle sharing (ever) and last use.