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Sexual history taking

Key Learning Points:

  • Taking a sexual history can be uncomfortable for medical students, doctors and patients alike.
  • A comfortable and confident doctor will put the patient at ease and obtain a through history
  • Ensure it is conducted within a private environment. 
  • Offer a chaperone if it would put the patient at ease, particularly if an examination is to take place following the history.
  • It may be wise to ask partners, friends or family to leave the consultation room. It is possible their presence can hinder the accuracy of the history.
  • Inform patients that you are going ask them some sensitive and personal questions as part of the consultation and obtain their consent to proceed.
  • Avoid sounding judgemental in your questioning!
  • Do not forget to ask red flag questions! 
  • Reassure patients that everthing discussed will be kept confidential.
  • Do not make assumptions about the patient, use gender neutral questioning such as "your partner?" instead of "your husband?"

 

    It may help to phrase your introduction very carefully to calm and reassure the patient, something along these lines may help:

    "I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health.

    Just so you know, I ask these questions to all of my adult patients, regardless of age, gender, or marital status, so please don't feel like I am judging you. These questions are as important as the questions about other areas of your physical and mental health.

    Like the rest of our visits, this information is kept in strict confidence. Do you have any questions before we get started?"

          General Approach

          Initially question to obtain the patient's background:

          1. Name
          2. Age
          3. Ethnicity/ Nationality
          4. Occupation

             

            A general framework would be:

            1. Presenting complaint
            2. History of the Presenting complaint- aiming for a symptom review
            3. Last sexual intercourse
            4. Previous sexual partners in the last 3 months
            5. Previous STIs?
            6. Gynaecological history
            7. +/- Obstetric history
            8. System review, especially GU symptoms
            9. Past medical Hx
            10. Past surgical Hx
            11. Current Medications (particularly antibiotic use within the past month.)
            12. Allergies
            13. Family Hx
            14. Social Hx (Smoking/ Alcohol/ Recreational drug use- particularly IV drug use)

                Presenting Complaint + History of the Presenting Complaint

                Women can present with:

                • Urethral discharge
                • Vaginal discharge
                • Vaginal bleeding
                • Dysuria
                • Dyspareunia
                • Warts
                • Rash, itch
                • Ulcers
                • Abdominal pain
                • Changes in menstrual cycle or irregular bleeding

                 

                  Men can present with: 

                  • Urethral discharge
                  • Dysuria
                  • Skin changes eg. warts/ ulcers 
                  • Peri anal/ anal symptoms

                   

                      HPC (like any other history taking) note the following:

                      With vaginal/urethral discharge:

                      • Onset (Sudden or gradual)
                      • Colour (any blood mixed in?)
                      • Odour? 
                      • Amount?

                      Different STI's have different presentations.

                       

                        Abdominal Pain:

                        • Use the mnemonic SOCRATES to guide your questioning
                        • Cyclical? (endometriosis as opposed to PID)
                        • Duration/ type/ radiation
                        • Precipitation or relief?

                         

                        Dysparaeunia:

                        • Recent onset or has it always been there?
                        • Pain felt superficial, deep or both
                        • Before, during or after sexual intercourse
                        • Anything else bring on the pain (rule out IBS)
                        • Childbirth (following episiotomy)
                        • On climax? (uterine pathology)
                        • On excitation? (bartholin cyst abcess)
                        • On entry? (vaginismus)

                        Always rule out sexual abuse/genital mutilation with dysparaeunia

                         

                        Vaginal bleeding:

                        • Amount of bleeding / discharge
                        • Presence of clots (PID may lead to menorrhagia)
                        • Timing (post-coital, intermenstrual)
                        • Progression
                        • Predisposing events
                        • Any investigation or treatment to date

                        Bladder symptoms:

                        • Dysuria/ frequency/ blood
                        • Foul smell urine?
                        • Hesitancy?
                        • Incontinence?

                          Ulcer:

                          • Duration?
                          • Genital, peri anal or anal?
                          • Border. Punched out? (HSV). Sharply demarcated (syphiis)
                          • Depth? (usually deep in syphilis and shallow in herpes)
                          • Primary lesion?
                          • Number of lesions? (syphilis usually one, herpes multiple)
                          • Itchy? (Hepres/ Syphilis)
                          • Painful? (Chancroid) 
                          • Painless? (Primary syphilis/ Donovanosis)
                          • Recurrent? (Herpes)
                          • Surrounding lymphadenopathy? Painful lymph nodes (herpes)
                          • General symptoms of systemic infection?

                          Causes: Herpes/ Syphilis. Uncommonly: lymphogranuloma venerum/ donovanosis/ Haemophillus Duceryi (chancroid).

                          Consider: psoriasis/ local trauma/ squamous cell carcinoma/ drug reactions eg tetracyclines and sulphonamides/cellulitis

                           

                            Warts:

                            • Genital, peri anal or anal? (location varies on sexual practice)
                            • Systemic infections/ Ulcers (beware condylomata lata a sign of secondary stage syphilis mimics a genital wart)
                            • Pruritis?
                            • Discharge

                            Causes: commonly: HPV. less commonly: secondary syphilis/ squamous cell carcinoma/ epidermoid cysts/ molluscum contagiosum

                               

                              General symptoms associated with infection:

                              • Fever and rigors
                              • Pelvic Pain
                              • Dysuria
                              • Vaginal/Urethral Discharge
                              • Regional lymphadenopathy

                               

                              Symptoms associated with malignancy (beware they can be asymptomatic in the early stages):

                              • Weight loss
                              • Loss of appetite
                              • Post coital/ Intermenstrual bleeding (Cervical/Endo Ca)
                              • Dysparaeunia (Cervical/Endo Ca)
                              • Abdominal distension (Ovarian Ca)
                              • Ascites (Ovarian Ca)

                              See individual articles on fastbleep for more detailed information about each presentation.

                                  Sexual History

                                  When exploring sexual history, discuss:

                                  • When did they last have sexual intercourse?
                                  • Orientation- different practises predispose to certain infections. 
                                  • Are they in a relationship?
                                  • Gender of partner
                                  • Contraception (those used previously and currently; especially barrier methods; types; compliance; duration)
                                  • Sites penetrated
                                  • Dyspareunia
                                  • What is the locality or nationality of the patient's partner?
                                  • Number of partners over the last 3 months (this changes from area to area)- this is for contact tracing. If the pt has not been active in the last 3 months, enquire about last sexual encounter further back. 

                                  It may help to phrase your line of questioning using the 5 P's

                                  1) Partners

                                  • Number and gender- especially over last 12 months
                                  • Regular, ex-regular or casual? 
                                  • Need to ascertain if partner's ethnic origin is overseas, as they may be at risk from foreign travel to areas of higher incidence of certain diseases compared to the locality
                                  • Are they suffering from similar symptoms?

                                   

                                    2) Practices (essential to determine testing sites/ likely pathogens)

                                    • Vaginal
                                    • Oro genital
                                    • Genito oral
                                    • Anal (give)
                                    • Anal (recieve)

                                     

                                      3) Protection From STDs (assessing the pts. risk consider discussing risk reduction counselling). Use condoms/ barrier method all/some/none of the time?

                                       

                                      4) Past History of STD (a previous history places a pt at greater risk of further infection)

                                       

                                      5) Prevention of Pregnancy

                                       

                                      A common place students lose marks in osces is failing to ask about anal/oral sexual practises. And failing to clarify the individuals orientation (ie male who has sex with men)

                                       

                                      In GUM clinics to probe for at risk individuals, it is essential to pick up those who are sex workers, or solicit them.

                                      The best way to ask this is:

                                      "Have you ever paid or been paid for sex?"

                                        Obstetric and Gynae history

                                        For a Gynae history :

                                        • Last menstrual period/ Regularity of periods
                                        • Age of menarche
                                        • Painful/ Heavy periods?
                                        • Contraception used?
                                        • Previous swabs taken? Smear?

                                         

                                        For Obstetric History:

                                        • Gravida? Para?
                                        • Problems before/ during/ after pregnancy?
                                        • Lactating?
                                        • Previous TOP?

                                         

                                        Red Flag Symtoms

                                        Infections:

                                        HIV- pyrexia of 2+ weeks; swollen lymph glands; Rash; night sweats; diarrhoea >1month; Unexplained Weight loss>10%; 

                                        Herpes-painful shallow ulcers, which may coalesce; fever; myalgia; headache; painful lymphadenopathy; aseptic meningitis may develop and urinary retention. Recurrent episodes.

                                        Syphilis- firm painless chancre; painless lymphadenopathy; fever; arthralgia; condylomata lata; dermatopathic changes around body; snail track ulcers in oropharynx and genitals. Late stage tertiary signs- Aortic regurgitation; neurosyphilis; general paresis of the insane; tabes dorsalis. 

                                         

                                        Malignancies:

                                        Post Menopasual Bleeding- Endometrial Cancer proven otherwise

                                        Intermenstrual/ Post Coital Bleeding- Cervical cancer

                                        Amenorrhea - Ovarian Carcinoma

                                        Haematospermia- Prostate/testicular cancer (particularly if >40yo)

                                        Testicular lump/ asymmetry- Testicular cancer

                                         

                                        Other emergencies:

                                        Testicular swelling/ acute lower abd pain- Testicular torsion (delay in treatment may lead to necrosis of testis affecting future fertility)

                                        Abdominal pain and vaginal bleeding- Ectopic Pregnancy till proven otherwise, but consider PID

                                        In General However Raise suspicion if these are encountered: 

                                        • Fever
                                        • Flank pain or tenderness
                                        • Recent Weight loss
                                        • Immunocompromised patient
                                        • Recurrent episodes (including frequent childhood infections)
                                        • Known urinary tract abnormality

                                         

                                        Important information for Gynaecological history taking



                                        Algorithm for assessing Dyspareunia and Vaginal Discharge



                                        Causes of Vaginal Discharge



                                        Urethritis and Discharge in Men



                                        To Finish off!

                                        • Thank the pt for being honest and for giving their time
                                        • Praise any protective or positive practises the pt engages in. 
                                        • For pts at risk of STD encourage regular testing/ use of protective practices (monogamy; condoms)
                                        • Address concerns regarding high risk practices the pt may have- this concern may encourage the pt to accept a counselling referal

                                         

                                         

                                        Reference:

                                        1. Essential OSCE Topics for Medical and Surgical Finals; Kaji Sritharan, Vivian A Elwell, Sachi Sivanathan; Master Pass; 2008; Racliffe Publishing Ltd.
                                        2. Lectures: Sexually Transmitted Infections (2); Dr.Orange, Consultant Microbiologist, Ninewells Hospital, University of Dundee.
                                        3. A Guide To Sexual History Taking: US Department of Health and Human Services Centers for Disease Control and Prevention
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