How to Take a Sexual Health History Efficiently and Effortlessly.
Introduction
As an integral part of a patient’s overall health, a sexual health history is a valuable skill to require and is essential in assessing sexually transmitted infections (STIs), genital symptoms, pregnancy and sexual functions. Regarding the nature of the questions, the examiner needs to make the patient at ease and comfortable talking about this topic.
Often, patients are embarrassed and may feel ashamed of themselves; thus, communication skills need to be relevant, patient-centred and skillfully done. Try not to sound as if you are going through a checklist (even though you are) and make the patient feel that this is a safe space to talk about intimate issues. Only ask relevant questions and stay on the topic of the discussion. The language used is key; for example, “sex” may not describe penetration. Do remember to demonstrate empathy, actively listen and watch for verbal and non-verbal cues. During the consultation, use correct eye contact, be open and relaxed, mirror the patients’ language (if possible), show professionalism, avoid interrupting and establishing a rapport is vital, especially in sensitive matters. It is always appreciated in a sexual health history to be the first to use sensitive words such as purulent, discharge, vagina, penis, anal, receptive/insertive, et cetera. Finally, signposting and summarising demonstrate the exchange of information and whether both parties understand the situation clearly.
Some tips for eliciting a sexual health history is to:
Make it routine, confidential, and free of assumptions related to age, anatomy, gender and ability.
Practice asking the questions; the more often it is done, the easier and natural it will become.
Explaining why a sexual health history is essential to the patient.
Ask about sexual function and satisfaction, not just STI risks.
Start initially with open-ended questions.
Normalise “less desired” responses: “Many people do not use condoms every time they have sex. How often do you use condoms?”.
Don’t be so concerned about asking something in the “right” way that the conversation becomes a robotic rather than a professional but natural interaction.
Tone and rapport matter as much as the questions themselves.
Give patients options to answer questions indirectly.
Sexual health history structure
Before starting
Wash your hands and don PPE if appropriate.
Confirm you have the right patient.
Introduce yourself to the patient, including your name and role, and use an opening statement to explain and gain consent. For example, “today, I would like to take a sexual health history from you which involves personal questions. These are routine questions that we ask every patient and in order to find out what STIs to test you for, assess risks or to find out what could be causing your symptoms. Please don’t take any of the questions personally, and if there are questions you are not willing to answer or would like to end the consultation, that is perfectly fine. Would that be okay?”.
Talk about privacy and confidentiality, which ease and reassures the patient about the consultation. You may say, “everything that we will be discussing is confidential and remains within the clinical team”. Sometimes a minor may come in where additionally you may say that parents have no rights to know about what was spoken or found during the consultation. Confidentiality may be broken if the patient is at risk of harming others or themselves to whom they will be made aware.
Finally, ask about ethnicity, such as whether the patient is an Aboriginal and Torres Strait Islander, Caucasian, et cetera. Studies have shown different ethnicities are more at risk of acquiring STI(s) due to low social-economic status, amongst other risk factors.
Be aware of the context of the social issues patients may present during the sexual health history, such as the patient’s age, the age of their partners, involvement of alcohol/drugs, abuse/assault and consent.
Symptoms / SOCRATES
Use open-ended questions to explore the patient’s presenting complaint, such as do you have any symptoms you are worried about, what’s brought you in to see me today or tell me about the issues you’ve been experiencing? Do provide time for the patient to explore without being interrupted.
If there is pain, use SOCRATES to assess.
Ask the patient to point at the location of the pain (suprapubic/abdominal/pelvic/flank).
How and when did it start, gradual/sudden, first appeared.
Specific character.
Moves/radiate anywhere.
Association, alleviation and exacerbation.
Severity.
Do you have pain on urinating? Increased frequency of urinating? Is there urgency in urinating?
Do you have any abnormal discharges such as clear, purulent, cheese-like, frothy, green/yellow? Assess the volume of discharge and consistency.
Is there a smell?
Is there blood present or in the urine? Is there blood after sex?
Is there blood or pain during sex?
Have you noticed any lumps, bumps, skin changes, ulcers or rashes?
If the patient is a female, ask:
Inter-menstrual vaginal bleeding.
Post-menopausal bleeding.
Vulval skin changes and itching.
If the patient is a male, ask:
Testicular pain or swelling.
Ask for systemic questions such as rash, malaise, fever, loss of weight, night sweats and reactive arthritis signs.
Try an facilitate the patient to expand on their presenting complaints if possible.
The 5 Ps
Signposting gives a warning shot to the patient that more in-depth and personal questions are about to be asked surrounding their sexual health history. This is all for their benefit in assessing risks and is valuable for management and investigations. For example, you may say, “I am going to move on to the next section. It is more personal and in-depth; these questions are asked to assess STIs’ risk accurately. These are routine questions, and every patient gets asked the same questions. Again, please don’t take them personally, and if you wish not to answer or finish the consultation, that is perfectly acceptable”.
Previous STI(s) and screening
Some STIs are asymptomatic for months, hence assessing the patient’s past sexual health history and screening is essential.
Ask the patient if they had an STI screen before. If they reply with yes, ask when it occurred and the screening outcome, such as any results showing positive to any STIs.
If positive, what were the outcome and the treatment?
If the patient is a female, ask about their last cervical screens if appropriate.
Partners
Assess if the patient is sexually active, however being sexually active is ambiguous. For example, what is the actual time frame when one is sexually active? Instead, ask the patient, “in the past three months, how many sexual partners have you had?”. This helps in knowing the number of partners and the patient’s sexual activities. The three-month time frame is utilised as it is generally the time frame for any STIs to present themselves.
When was their last sexual encounter?
Assess if there was consent or not.
Assess the gender of the partners and the patient’s preference, such as do they have sex with men, women, trans, non-binary or combination/all? None of these questions is asked randomly and is relevant as assessing the gender helps in the risks and likelihood of acquiring STIs.
Ask if they know their current partner’s status, past STI screens and outcome if they were positive.
Were these sexual encounters with a long term partner or a more casual sex encounters?
Practices
Clarifying the type of sex is vital in assessing risks.
Does the patient have vaginal, anal or oral sex?
Does the patient give or receive oral and/or anal sex?
Were there more than one person at a time?
Was there drugs or alcohol use before or after sex?
If the patient is a man who has sex with men, ask if he is receptive, insertive, or versatile. These questions help in STI risks and swabbing areas if needed. Generally, whichever anatomical area involvement will require adequate swabbing.
Protection
It is not sufficient to ask a patient if they use protection or not. For example, one may say they use protection once every ten sexual acts and still mention that they do use protection; hence it is vital to ask if the patient uses condoms none of the time, some of the time, most of the time or always when having sex. This question is fundamental in assessing the risks of STI transmission. Bear in mind protection is not just about condoms; it can also be making sure the patient is up to date with vaccination and using PrEP if appropriate.
If barrier contraception were used, were there any mishaps, breakage, or fallen off?
When was the last time the patient had any recent sex without a condom?
If the patient does not use any protection, recommend in a non-judgemental way of its usage.
Do think of doing an HIV assessment if required and appropriate. These include the HIV risk factors:
Has the patient had sex with a partner who is HIV positive?
Has the patient had sex with a bisexual man or a man in a homosexual relationship?
Assess partners demographics.
Ask the patient if they inject drugs or if their partners inject drugs.
Assess if the patient had sex with sex workers.
Ask the patient about immunisation for hepatitis A/B and HPV.
Pills
If the patient is a woman having sex with men, ask if they use any form of contraception. If yes, assess adherence if appropriate. If no, ask if they wish to get pregnant but not in a way to shame the patient for not using any contraception. Finally, ask if they wish to talk about using a form of contraception.
Get a menstrual history including:
The average duration of their periods and any recent changes.
Quantify flow, any clots present?
When was their last period?
Their first period, and if relevant, their last period before menopause.
Regularity and frequencies.
Discharges/spotting present.
Pain present.
If the patient is a man having sex with men, ask if he uses PrEP. If yes, assess adherence if appropriate. If not, ask if they wish to talk about the use of PrEP.
Closing statement
Summarise key points and ask if the patient has any questions or if they still have any concerns that have not been addressed.
After summarising and analysing the potential risks on the information given, let the patient know what happens next in terms of investigations. A swab, urine and/or blood sample may be taken to investigate the cause. Book an appointment in a week to discuss the results, or if the results come in earlier, call the patient to schedule an appointment or give the results via telephone. Finally, commence on adequate management and treatment if appropriate.
It is vital that the patient’s partner(s) get treated and notified. However, the patient does not need to notify their past sexual partners as it can be done anonymously via contact tracing. Depending on the causative agent, the patient may have to come back in 3 months for a checkup and potentially another STI screen.
Reaffirm confidentiality and thank them for their time.
Dispose of PPE and wash your hands.
Published 15th July 2021. Last reviewed 5th December 2021.
Reference
ASHA authors. Taking a sexual history & contact tracing. STI Guideline website.
http://www.sti.guidelines.org.au/resources/how-to-take-a-sexual-history#how-to-take-a-sexual-history. Accessed December 3, 2021.
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Jones R, Barton S. Introduction to history taking and principles of sexual health. Postgrad Med J. 2004;80:444-446.
Kevin LA. Taking an Affirming Sexual History. Fenwayhealth website.
https://fenwayhealth.org/wp-content/uploads/10.-Taking-an-Affirming-Sexual-History-Ard.pdf. Accessed December 3, 2021.
Tomnay J and authors. Introduction to Contact Tracing. Australasian Contact tracing Guidelines website. http://contacttracing.ashm.org.au/. Accessed December 3, 2021.
Kingsberg SA. Taking a sexual history. Obstet Gynecol Clin North Am. 2006;33(4): 535-547. doi: 10.1016/j.ogc.2006.09.002.
Presswell N, Barton D. Taking a sexual history. Australian Family Physician. 2000;29(6), 535-539.
Reno H, Park I, Workowski K, Machefsky A, Bachmann L. A Guide to Taking a Sexual History. CDC website. https://www.cdc.gov/std/treatment/sexualhistory.pdf. Accessed December 3, 2021.
