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Taking a Sexual History

 

Taking a sexual history can be daunting for both the clinician and patient and is often incomplete due to embarrassment. This doesn't have to be the case if both parties are prepared and acknowlege that the questions are of a personal nature and can cause some discomfort. Before starting:

  • Think about where you are and if anyone may be able to overhear your conversation, aim to talk to your patient in a quiet place where their confidentiality can be maintained.
  • Place yourself so that you are facing them, ideally without a desk between you. 
  • If there are any partners or relatives in the room, ask the patient if they would like to be alone or not whilst talking to you.

 

  • Introduce yourself and explain why you need to take a sexual history.
  • Give assurance that their confidentiality will be maintained.
  • Prepare them by informing them that you will be asking questions of a delicate nature.
  • Provide assurance that these questions are asked universally to all patients from whom the history is taken from and are not specific to them.
  • Have a relaxed and non-judmental attitude, take your cues from the patient and be aware of their body language, if they are showing signs of discomfort (such as avoiding eye contact, flushing, fidgeting) then change your style of questioning. Some patients prefer a more formal discussion whereas others require a more informal tone, this will depend on gender, age and patient's preference.
  • Reassure them that if they feel uncomfertable answering any of your questions then they should feel free to tell you this and you will move on to another topic in the history. However if you have more information it may be easier to make an accurate diagnosis.

Patient Information

 

Begin by eliciting some basic information such as:

  • Age
  • Occupation
  • Marital status

Presenting complaint

 

Elicit the reason for attendance with an open question such as:

  • How can I help you?
  • What brings you to see me today?

History of Presenting Complaint

 

Ask more in depth questions about the problem

  • The duration of the problem, "when did you first notice it?"
  • Severity, "how has this affected you?", "is it getting better, worse or staying the same?"
  • Previous experiences, "have you ever had this before?"
  • Aggravating or relieving symptoms, "has anything made it better?" you can also asked if they have tried any medications to try an relieve the symptoms. 
  • Any associated symptoms such as pyrexia, a rash or lymphadenopathy. Gonorrhoea and Chlamydia can cause a reactive arthritis with joint inflammation. It is also useful to ask about eye symptoms. When there is arthritis coupled with conjunctivitis or uveitis and urethritis (dysuria) in men or cervicitis in women, it is labelled as Reiter's syndrome. In rare cases patients can present with symptoms of meningitis or endocarditis, however this is more likely in immunocompromised patients. 

Once you have explored their presenting complaint, it can be useful to do a symptom review to exclude any common symptoms of STIs. The questions asked differ for men and women:

Women

  • Abdominal pain
  • Vulval skin changes
  • A change in vaginal discharge
  • Changes in menstrual cycle or irregular menstrual bleeding
  • Dysuria, "do you experience any burning when you pass urine?"

Men

  • Genital skin changes
  • Presence of urethral discharge
  • Dysuria
  • Peri-anal/anal symptoms in gay men

Vaginal discharge is a common presenting complaint amongst women and some features indicating different causes are summarised in the table below:



Last Sexual Intercourse

 

Begin to ask more indepth questions about their sexual history, starting with their last sexual intercourse (LSI). With regard to their their last sexual encounter ask about:

 

  • Current relationship status, "are you currently in a relationship?"
  • Gender of their partner (never assume or guess what a person's sexual orientation is)
  • If they are in a relationship enquire about the length of time, if it is a casual or regular partner and if it is regular have been other sexual partners outside the relationship?
  • Ask about the the type of intercourse, "during your last sexual encounter did you have oral (giving or receiving), anal or vaginal sex?"
  • If there was use of condoms or barrier contraception. 
  • If the patient knows of any symptoms experienced by their partner, and their country of origin.

 

Previous Partners

 

Elicit a history of the number of partners encountered in the last 3 months (if the patient is tested for HIV at this consultation a negative antibody test would not rule out HIV contracted in the last months, therefore any high risk behaviour within this period should be identified). 

 

Ask the same questions as outlined in 'Last Sexual Intercourse' for each partner:

  • Gender and relationship with partner
  • Type of sexual intercourse
  • Use of barrier contraception
  • Place or origin and symptoms in the partner

 

All men should be asked if they have had sex with another man in the past, this should be done with sensitivity.

 

Contraceptive Use

 

To evaluate a woman's risk of pregnancy:

 

  • All women should be asked about their contraceptive history and if they are using non-barrier methods of contraception.
  • Elicit their compliance in using their chosen method of contraception reliably. 
  • If they are not using any contraception establish if this is because they are trying to conceive. 
  • Ask about the date of their last menstrual period (LMP) - this is the date on the first day of the last period, and total cycle length.
  • If she is over 25 years old ask her when her last cervical smear was taken and if there have been any abnormal results in the past.

 

Risk Assessment

 

Establish if they have engaged in any behaviour that is high risk for HIV, Hepatitis B or C. These behaviours are highlighted in the table below:

 

Past Medical History

 

  • Have they previously contracted an STI?
  • When was it diagnosed and what treatment was given?
  • Was the full course of treatment completed?
  • Establish if they suffer from any medical conditions, ask about diabetes, depression and dermatological conditions.
  • Any previous pelvic or gynaecological surgery?
  • Obstetric history including number of pregnancies and their outcomes. Mode of delivery, any antenatal or post partum complications for the mother or child.
  • Gynaecological history, if not already elicited, any history of dysmenorrhoea (painful periods), menorrhagia (heavy periods) or dyspareunia (pain during intercourse)?

 

Summary of High Risk Behaviours

Drug History

 

  • Are they taking any prescribed or over the counter medication?
  • Any herbal medication?
  • Are they allergic to any medications?

 

Social History

 

  • What type of accommodation do they live in?
  • Who do they live with?
  • Do they smoke cigarettes? How many? For how long?
  • Do they drink any alcohol? How much (quantified in units)
  • Do they take any recreational drugs?

 

Conclusion

 

Finish by summarising what the patient has told you and provide them with the opportunity to add anything they think you have missed or correct you if there has been a misunderstanding.

 

Allow them to ask you any questions they may have.

 

If they need to undergo an examination tell them that this is what will happen next, why you need to do it and what it will involve. This can also be a good time to discuss any tests you feel they will need. If you do organise for serology or microbiology tests ensure that you have informed the patient of how the results will be delivered to them.

 

If you feel that they are at risk of contracting an STI (or if female, may be pregnant) make a plan for what will happen next, this may include post exposure prophylaxis (PEP) or emergency contaception. Councel the patient appropriately and provide education about safe sex to prevent future high risk behaviour.

Document the consultation in the medical notes clearly.

 

Tips

 

It can be useful to remember the different components of the sexual history as the "5 P's" these are:

  • Partners
  • Practices
  • Protection from STIs
  • Past history of STIs
  • Prevention of pregnancy

 

The different aspects of the history mentioned above fit into one of these headings.

 

  • Do not feel uncomfortable if there a silences during the consultation, this is normal in conversation and the time can be used to think about what has been said so far and how you will phrase the next question.
  • A useful technique to try and elicit further information is to repeat the last word that the patient said and phrase it as a question, such as, "and then I felt this pain," would have the response, "pain?"
  • If you are taking a history from someone under the age of 16 an assessment needs to be made of their competence to consent to a history and examination as decribed in the Fraser Guidelines. The assessment needs to be documented in the notes and take care when taking the history to assess for any child protection issues. 

 

References

  1. Faculty of Sexual and Reproductive Healthcare Clinical Guidance, February 2012. Management of Vaginal Discharge in Non-Genitourinary Medicine Settings [Online] London, Available at: www.fsrh.org/pdfs/CEUGuidanceVaginalDischarge.pdf
  2. French, P., 2007. BASSH 2006 National Guidelines- consultations requiring sexual history-taking. International Journal of STD and AIDs. 18: 17-22
  3. Tomlinson, J., 1998. ABC of sexual health; Taking a sexual history. British Medical Journal. 317: 1573
  4. Sexual Advice Association, June 2011. How to take a sexual history: a guide for health professionals [online] London. Available at www.sda.uk.net/sh
  5. US Department of Health and Human Services Centers for Disease Control and Prevention, A guide to taking a sexual history [online] Atlanta. Available at: www.cdc.gov/std/treatment/SexualHistory.pdf
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