Taking a sexual history

2015 2016 1
vers 280715
 Aim
To enable participants to take an appropriate
sexual history to facilitate the diagnosis and
management of sexually transmitted infections

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 Learning Outcomes for this session
By the end of the session participants will be able to describe:
the key components of a sexual history
the concerns of a patient who suspects that s/he may have an
STI and describe strategies to deal with these
the verbal and non-verbal factors which may affect a
consultation
the experience of a consultation about STIs from a patient's
perspective
ways of raising the issue of STIs in a routine consultation.

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 Presentation overview

Why take a sexual history?

Pitfalls and barriers

What you need to know

How to ask the questions-including practice using case

scenarios and role play
 Why take a

sexual history?

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 Why take a sexual history?
to assess clinical condition
to assess risk for STIs (including HIV)
looking for additional risks (PEPSE, Emergency Contraception)
plan tests
when is the best time to take tests?
which tests should be taken and from which sites?
enable partner notification
identify need for immunisation
Identify need for health promotion

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What's different about a sexual history?

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What's different about a sexual history?

Emotional issues
Emotive issues
Embarrassment
Usually involves other people
Attendance as a contact (asymptomatic)
Moral/legal issues

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What are the barriers to taking a good
sexual history?
Patient and provider embarrassment

Provider stereotyping or misinterpretation

Patients not expecting the questions

Patient anxiety about confidentiality

 Assumptions
Based on?
Personal opinion
Previous experience

Stereotyping:
May influence both clinician AND patient
Common stumbling block in sexual history taking
Can be difficult to avoid- natural human response
Increased risk of misunderstanding:

consultation is hurried

provider is embarrassed

patient is embarrassed/anxious

when there is a language barrier

 Language barrier

Always avoid using friends or family to interpret

Consider the possibility of domestic abuse

or sexual abuse or trafficking

Use accredited interpreting service

Asylum seekers have specific issues:

- They may have suffered rape/torture
- Often come from higher risk areas for STIs
- Poverty may be forcing them to sell sex
What concerns might a patient have who
suspects they might have an STI -

or if you bring up the subject of STIs

in the consultation?

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Embarrassment, anxiety, fear and preoccupation can
affect patient recollection of sexual history

Talking about this is SO EMBARRASSING

Do I have a disease? Is it curable?
Will I be off work?
What are the long term effects? Fertility?
How did I catch it?- my partner has been cheating!
What about my baby, my toddler?
Doctor will think Im disgusting promiscuous, a slut!
How am I going to tell my partner?
Can other people over hear what Im saying?
I dont want to be examined!
 How to request the patients permission

Sometimes these symptoms are related to a sexual

infection (or pregnancy).

Would it be ok if I ask you some questions about your

sexual practice?

(or) about your partners and the type of sex you

have?
 Reassure re confidentiality
Everything you tell me is
confidential

We dont share your personal

information with any one else

Your records just stay here in this

clinic
How can we make
it easier for the
patient to talk?

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 Patient embarrassment
Best allayed by a sympathetic, non-judgemental, entirely un-
embarrassed clinician
Who is comfortable asking intimate questions

Practice - reduces our discomfort.

(and therefore the patients)

Be confident of which questions

are relevant and why

A well rehearsed patter reassures the patient

that these questions are a normal part
of a consultation
How can we make it easier to talk?
Dont appear or be judgmental/disapproving
Dont be embarrassed
Be aware of difficulty talking about sex
Avoid Jargon / medical language
Reassure re confidentiality
Ensure privacy
Be ready to reassure
Give time to explain
Allow time / avoid interruptions
Be flexible
Focus on patient's perceived needs

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How can you address issues of sexuality
sensitively when talking with patients?

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What about raising sex in a non-related
consultation?

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 Patients not expecting the questions

Why are you asking me that!

We know why- but the
patient may have no idea!

The patient may be shocked or offended

Generally 2 scenarios in the consultation:

Patient not surprised when you ask them about
sex
Patient very surprised when you ask them
about sex
So-what do you need to know?

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 So-what do you need to know?
Symptoms and their duration

Recent sexual activity (and condom use)

Partner history
(including partner symptoms and any known or suspected STIs)

Sexual orientation

Previous history of STI

Medical, gynaecological and drug history

Additional risk factors for blood-borne viruses

 So-what do you need to know?

Dont forget:

1. Assess for Emergency Contraception

2. Assess for PEPSE

http://man2man.ie
 Regular v casual partners
Regular partner
Someone with whom they have sex on a regular basis i.e.
spouse, civil partner, boyfriend/girlfriend

Casual partner
Someone they do not know and do not intend to have sex
with again
Someone they know but do not have a regular
relationship with.

(Be alert to the possibility of non consensual sex , payment for

sex)
 Blood-borne virus risk assessment

HIV test before

Injected drugs or snorted drugs
Partner who is IDU
Partner from abroad or who was born outside the UK
Heterosexual man- Ever had sex with a man?
Heterosexual woman- Ever had sex with a man who has sex with other
men or had sex with a woman?
Ever paid or been paid to have sex
Had a sexual partner you suspected might have HIV or Hepatitis
Had any unsafe body piercings/tattoos
Had a blood transfusion (UK pre 1992) or operation/injection abroad
Strategies for successful history taking
Ensure privacy and minimise distraction
Introduce yourself
Listen: find out what he/she wants from you
Deal with his/her concerns.
Explain confidentiality
Explain what to expect & need to ask detailed questions
Don't use jargon
Anticipate concerns
Reassure early and appropriately
Empathy

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Public Health Strategies to control STIs
Appropriate epidemiologic targeting- target high risk groups
Primary prevention and access to means of prevention
condoms, information
Provision of effective clinical services to shorten the
duration of infectivity
An enabling environment for prevention among
marganilised populations; increased access to health
seservices
Reliable data to guide decision-making surveillance, STI
prevalence data.

2011 - 2012 31
 How to ask the questions

Practice makes it easier

 Clinical scenario 1
Helen, aged 20, has been on
your list for 3 years and
started the COCP 18 months
ago.
She is complaining of 3
months break-through
bleeding.
 Clinical scenario 2

Jim, aged 24 has recently

registered with your practice

He has pain in his testicles since

a rugby match.
 Clinical scenario 3
Bianca aged 16 has made an
appointment to talk to you about a
problem.
You have recently been on the STIF
course and are aware of the risk of
an STI ; as she is 16 you want to
enquire about a sexual history and
offer chlamydia testing.
 Clinical scenario 4

Kevin aged 23, has been on your

list for 4 years.
He last attended 6 months ago
for a course of vaccines before
going on a back packing trip to
Asia.
He now attends requesting an
HIV test.
 Clinical scenario 5
ROSIE
34 yrs old. Accountant.
Married mother of 2.
No relevant medical or drug history.
Smears up to date
IUS in situ- not expired
LMP 1/52 ago.
Complaining of:
Smelly, itchy vaginal discharge for about 2 weeks off and on, noticeably worse
past few days.
No other genital or gynae symptoms
No superficial or deep dysparunia.
No IMB or PCB. No dysuria

TAKE A RELEVANT SEXUAL HISTORY

 Avoid medical jargon

Patient may be too embarrassed to admit they dont understand you

Tailor your terminology to the patient

Be aware of possibility of offence around describing sexual orientation

(Gay or MSM tends to be more acceptable than Homosexual)
 Blood-borne virus screen
HIV test before .......... ... No
Injected drugs/snorted drugs No
Partner who is IVDU.. ?
Partner from high risk areas abroad Yes
Had sex with a woman or MSM Yes
Paid or been paid to have sex.. No
Had a partner you suspected might have HIV or Yes
Hepatitis
Unsafe body piercings/tattoos... No
Had a blood transfusion or operation/injection No
abroad..
 Things you might have missed
Screening for Trichomonas
Taking a rectal swab
Screening for HIV, STS, Hep B and C
Offering Hep B vaccination
Stressing importance of EWP bloods
Offering counselling for assault and sign posting to gay/bi-
sexual support groups
Discussing safe sex and risks of UPAI
Exploring her fears around STIs and suggesting partner
screening.
 Try this question format
Do you have sex with men-women-both?

Do you have a regular partner?

Yes..take details
No.When was the last time you had sex?..take details

Quantify total number of partners

- Have you had any other partners in the last 6 months?
- Any casual-one off partners?
For each different partner ask these same 5 questions:

1. Is your partner from round here? White local?

2. What type of sex did you have?

Do you ever have oral sex? (Sucking)
Do you ever have anal sex? (Sex up your bum)

3. Was that with a condom?

4. Oral sex question:

Is that you giving oral sex or receiving - having it done to you?
With a condom? P or UPOI (gives/receives)

5. MSM question:
When you have sex up the bum is that you going into him-insertive (IAI)
Or him going into you- receptive (RAI)
 Summary
Ensure privacy and confidentiality
Dont appear judgmental or make assumptions
Explain why you are about to ask personal questions
Signpost before asking questions about sexual activity
Have a clear idea about what questions are relevant,

i.e. that are going to alter your management

Only ask what you need to know at that point in time

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 Learning Outcomes for this session
By the end of the session participants will be able to describe:

the key components of a sexual history

the concerns of a patient who suspects that s/he may have an

STI and describe strategies to deal with these

the verbal and non-verbal factors which may affect a

consultation

the experience of a consultation about STIs from a patient's

perspective

ways of raising the issue of STIs in a routine consultation.

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