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Taking a sexual history is a key skill that all medical students need to learn. This guide discusses what questions need to be asked and how they can be phrased when taking a sexual history. 

It is really important to make sure you clarify the language the patient uses. “Sex” is not synonymous with penetration, and personal preference over descriptive words for genitals should be acknowledged where possible and appropriate. You also need to be aware of the array of social issues which you may come across during the process of taking a sexual history (e.g. age of patient/partner(s), alcohol or drug intoxication, partner notification, consent).

Check out the sexual history taking mark scheme here.

 


Opening the consultation

Introduce yourself – explaining your name and role

Confirm the patient’s details – name and date of birth

Explain the need to take a sexual history:

  • “Today I need to take a sexual history from you, this is going to involve me asking some personal questions. We ask these questions to accurately assess your risk of specific sexually transmitted infections, so please don’t take any of the questions personally. Everything you tell me is confidential within the boundaries of the team looking after your care. If however, we felt you or someone else was in significant danger, we might have to break this confidentiality, to prevent harm. If you would prefer not to answer a particular question or you’d like to stop the consultation at any point, please let me know.”

 

Gain consent:

  • “Is it ok for me to ask you some initial questions?”

 


Presenting complaint

It’s important to use open questioning to elicit the patient’s presenting complaint:

  • “So what’s brought you in today?”
  • “Tell me about your symptoms.”
  • Allow the patient time to answer, trying not to interrupt or direct the conversation.

 

 Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, so tell me more about that.”
  • “Can you explain what that pain was like?” 

 


Things to ask people with a vagina

Symptoms

We have included a focused list of the key symptoms to ask people with a vagina, followed by some background information on each, should you want to know a little more.

Key symptoms to ask about

  • Genital skin changes
  • Vulval itching or soreness
  • Dysuria
  • Abnormal vaginal discharge
  • Abnormal vaginal bleeding
  • Dyspareunia
  • Abdominal or pelvic pain
  • Systemic symptoms (e.g. malaise, fever)

 

Key questions to ask about each symptom

If any of the symptoms above are present, you need to clarify the following details about each of them:

  • Onset – “When did the symptom start?”
  • Duration – “How long did the symptom last for?”
  • Severity – “How severe is the symptom?”
  • Course – “Is the symptom worsening, improving, or continuing to fluctuate?”
  • Intermittent vs continuous – “Is the symptom always present or does it come and go?”
  • Exacerbating factors – “Are there any obvious triggers for the symptom?”
  • Relieving factors – “Does anything improve the symptom?”
  • Associated features – “Are there other symptoms that appear associated?” (e.g. fever/malaise)
  • Previous episodes – “Have you had this symptom previously?”

 

Pain

If the symptom is pain, you should use the SOCRATES structure for gaining further details:

Site – “Where is the pain?”

Onset:

  • “When did it start?”
  • “Was the onset sudden or gradual?”

Character:

  • “Is the pain sharp or a dull ache?”
  • “Is the pain intermittent or continuous?”

Radiation – “Does the pain radiate anywhere?”

Associated symptoms – “Are there any other symptoms associated with the pain?”

Time course – “What is the overall time course of the pain?” (e.g. worsening, improving, fluctuating)

Exacerbating or relieving factors – “Does anything make the pain worse or better?”

Severity – “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

 

 

Vaginal discharge

All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and abnormal vaginal discharge when taking a sexual health history.

You should ask if the patient has noticed any changes to the following characteristics of their vaginal discharge:

  • Volume – “Have you noticed any change in the amount of vaginal discharge?”
  • Colour (e.g. green, yellow or blood-stained) – “Have you noticed any change in the colour of your discharge?”
  • Consistency (e.g. thickened or watery) – “Have you noticed that your discharge has become more watery or thickened recently?”
  • Smell – “Have you noticed any change in the smell of the vaginal discharge?”

 

Several STIs can cause abnormal vaginal discharge:

  • Gonorrhoea and chlamydia commonly present with abnormal vaginal discharge.
  • Bacterial vaginosis typically presents with an offensive, fishy-smelling vaginal discharge, without any associated soreness or irritation.
  • Trichomonas vaginalis typically presents with yellow frothy discharge with associated vaginal itching and irritation.

 

Vaginal bleeding

Abnormal vaginal bleeding is an important symptom that can be relevant to a wide range of gynaecological disease.

Post-coital bleeding:

  • Post-coital bleeding refers to vaginal bleeding occurring after sexual intercourse.
  • Potential causes include infection (e.g. chlamydia and gonorrhoea), cervical ectropion and cervical cancer.

Intermenstrual bleeding:

  • Intermenstrual bleeding refers to vaginal bleeding occurring between menstrual periods.
  • Potential causes include infection (e.g. chlamydia and gonorrhoea), malignancy (e.g. cervical or endometrial cancer), uterine fibroids, endometriosis, hormonal contraception (e.g. Mirena coil) and pregnancy.

Questions to ask:

  • “Have you noticed any vaginal bleeding after sex?”
  • “Have you noticed any vaginal bleeding between your periods?”

 

Dyspareunia

Dyspareunia refers to pain that occurs during sexual intercourse. It has several causes including sexually transmitted infections (gonorrhoea and chlamydia), endometriosis, vaginal atrophy and malignancy.

The location of the pain can vary:

  • Superficial dyspareunia – pain at the external surface of the genitalia (e.g. genital herpes)
  • Deep dyspareunia – pain deep in the pelvis (more common with gonorrhoeal or chlamydial infection)

 

You should clarify the following details about the dyspareunia:

  • Duration and timing of the symptom:
    • “Do you ever experience any pain around the time of sex?”
    • “How long does it last?” 
    • “When does it occur?” (before/during/after)
  • Location of the pain (e.g. superficial or deep) – “Does the pain feel to be within the vagina, or deep in your abdomen?”
  • Nature of the pain (e.g. sharp, aching, burning) – “What kind of pain do you experience?”

Dysuria 

Dysuria can be a symptom of a simple urinary tract infection, but may also indicate an underlying sexually transmitted infection such as chlamydia, gonorrhoea, trichomoniasis or herpes.

Questions to ask:

  • “Do you have any pain or stinging when passing urine?”
  • “Do you feel you are passing urine more often?”

 

Vulval itching/soreness

Vulval itching and soreness are common symptoms which can be caused by a wide range of underlying pathology including:

  • Candida (thrush)
  • Bacterial vaginosis
  • Genital herpes
  • Chlamydia
  • Gonorrhoea
  • Vaginal atrophy occurs in post-menopausal women and can lead to itching and bleeding of the vagina
  • Lichen sclerosis appears as white patches on the vulva and is associated with itching

Questions to ask:

  • “Do you have any itching down below?”
  • “Have you noticed any recent vaginal soreness?”

 

Genital skin changes

Genital skin changes can occur secondary to several sexually transmitted diseases including:

  • Genital herpes – painful crops of blisters/ulcers (vagina and cervix)
  • Genital warts – non-painful lesions that can be located on the labia, clitoris, urethral meatus, introitus, vagina, cervix, perineum, perianal area and anal canal.

Questions to ask:

  • “Have you noticed any skin changes around your vagina?”
  • “Have you noticed any blisters, spots or ulcers around your vagina or anus?”

Abdominal or pelvic pain

Abdominal and pelvic pain has many possible causes, but in the context of sexual health, pelvic inflammatory disease (PID) secondary to chlamydia or gonorrhoea is relatively common. Another cause of abdominal pain not to be missed in females is an ectopic pregnancy. The acronym SOCRATES, shown above, provides a useful framework for asking about pain in a structured manner to help narrow the differential diagnosis.

 

 

Systemic symptoms

Sexually transmitted infections can also cause systemic symptoms such as:

  • Fever (secondary to pelvic inflammatory disease)
  • Malaise
  • Weight loss (e.g. HIV)
  • Rash
  • Swelling of large joints, conjunctivitis and cervicitis  (Reiter’s syndrome secondary to chlamydia)

Questions to ask:

  • “Have you felt feverish at all recently?”
  • “Have you noticed any rashes elsewhere on your body?”
  • “Do you have any swelling or pain in your joints?”

 

Menstrual history

A menstrual history involves clarifying the details of a woman’s menstrual cycle.

Menstrual cycle details

Duration:

  • “How long do your periods typically last?”

 

Frequency:

  • “How often do your periods happen?”
  • “Are they regular and predictable?”

 

Menstrual blood flow:

  • “Are your current periods heavier than your usual periods?”
  • “Have you been flooding through sanitary towels?”
  • “Have you been passing blood clots larger than a 10p coin?”
  • “Do you experience a lot of pain during your periods?”
  • “Are the heavy periods impacting your day to day life?”

 

Past gynaecological history

Cervical screening (known previously as the cervical smear):

  • Confirm the date of the last cervical screening test
  • Confirm the result of the last cervical screening test
  • Ask if the patient received any treatment if the cervical screening test was abnormal and check if follow up is in place

 

Previous gynaecological diagnoses and treatments:

  • Ectopic pregnancy
  • Sexually transmitted infections
  • Endometriosis
  • Malignancy (e.g. cervical, endometrial, ovarian)

 

Obstetric history

Current pregnancy (if relevant):

  • Gestation
  • Complications (e.g. small for gestational age)
  • Fetal movements – check they are normal if at an appropriate gestation

 


Things to ask people with a penis

To avoid repetition, for each of the following symptoms, you should apply the same questions shown in the previous “Key questions to ask about each symptom” section.

Symptoms

We have included a focused list of the key symptoms to ask people with a penis, followed by some background information on each of the symptoms, should you want to know a little more.

Key symptoms to ask about

  • Testicular pain or swelling
  • Itching or sore skin
  • Skin lesions (anogenital region)
  • Urethral discharge
  • Dysuria
  • Systemic symptoms (e.g. malaise, fever)

 

Testicular pain and/or swelling

Testicular pain and swelling may suggest a diagnosis of epididymo-orchitis, which is often secondary to chlamydia or gonorrhoea.

Questions to ask:

  • “Have you noticed any pain in your testicles?” (clarify the details of the pain using the SOCRATES method mentioned previously)
  • “Have you noticed any change in the size of your testicles?”

Itching and/or sore skin

Itching and sore skin in the genital region may be caused by infection with candida, herpes simplex virus or genital warts.

Questions to ask:

  • “Have you noticed any itching around your genitals?”
  • “Is the skin around your penis and/or testicles sore?”
  • “Is the head of your penis sore?”

 

Skin lesions (anogenital region)

The most common causes of new skin lesions in the anogenital region are genital warts (HPV) and herpes simplex. Genital warts are typically painless, however, patients sometimes can experience itching and bleeding. Genital herpes simplex lesions typically present as crops of painful blisters/ulcers in the genital area (including the urethra).

Questions to ask:

  • “Have you noticed any lumps, bumps or ulcers around your penis, testicles or anus?”
  • “Are the lesions itchy or painful?”
  • “Have you noticed any tingling or burning in the area of the lesions?”

 

Urethral discharge

Urethral discharge may suggest underlying chlamydial or gonorrhoeal infection.

Questions to ask:

  • “Have you noticed any discharge from your penis?”

 

Dysuria (including frequency, urgency, nocturia)

Dysuria can be a symptom of a simple urinary tract infection, but may also indicate an underlying sexually transmitted infection such as chlamydia, gonorrhoea or herpes.

Questions to ask:

  • “Do you have any pain or burning in your genitals when you pass urine?”
  • “Do you feel you are passing urine more often?”
  • “Is there any blood in your urine?”

 

Systemic symptoms

Sexually transmitted infections can also cause systemic symptoms such as:

  • Fever (secondary to pelvic inflammatory disease)
  • Malaise
  • Weight loss (e.g. HIV)
  • Rash
  • Swelling of large joints, conjunctivitis and cervicitis  (Reiter’s syndrome secondary to chlamydia)

 

Questions to ask:

  • “Have you felt feverish at all recently?”
  • “Have you noticed any rashes elsewhere on your body?”
  • “Do you have any swelling or pain in your joints?”

 


Sexual history: Last sexual contact

Sign-posting

Sign-posting here is of benefit to ensure the patient is prepared for the nature of the questions surrounding their sexual history.

  • “Next, I’m going to move on to discuss your sexual history, some of these questions are quite in-depth and personal. The reason we ask these questions is so that we can accurately assess the risk of sexually transmitted infections. We ask the same questions to everyone, so please don’t take anything personally. If you feel uncomfortable and would prefer not to answer, just let me know.”

 

Timing

Ask about the timing of the last sexual contact:

  • “When did you last have a sexual encounter?”

 

Consent

Ask if the patient feels this sexual encounter occurred with their consent:

  • “Was this sexual encounter consensual?”

 

Relationship

Ask if this was a regular sexual partner or a one-off casual sexual encounter:

  • “Was this a regular sexual partner, or a casual sexual encounter?”

 

Partner demographics

Clarify the sex and country of origin of the partner:

  • “What sex was the partner in question?”
  • “What country was the partner from?”

 

Types of sex involved

You should clarify what type of sex was involved in the encounter (e.g. oral, vaginal, anal):

  • “What type of sex was involved in this sexual encounter?” 
  • “Did you give or receive oral sex?”
  • “Did you have vaginal sex?”
  • “Did you give or receive anal sex?”

 

Contraception

Clarify the type of contraception used and the consistency of usage:

  • “Did you use any form of contraception for the sexual encounter?”
  • “Was any barrier contraception used during sex?”
  • “Was there any issues with the contraception used?” (e.g. condom splitting)
  • “Was there any point at which contraception was not used during the sex?”
  • “Did you use contraception for every sexual encounter with this individual?”

 

Other sexual partners

Ask about other sexual partners in the last 3 months:

  • “Have you had any other partners within the last 3 months?”  – if so, repeat the above for each

 


Past medical and surgical history

Medical or surgical problems:

  • “Do you have any medical conditions?”
  • “Is there anything you see the doctor regularly for?”
  • “Have you been in a hospital for anything in the past?”

Previous sexually transmitted infections (including partners)

 


Drug history

Current medications:

  • “Do you take any regular medications?”

 

Recent antibiotics:

  • “Have you taken any recent antibiotics?”

 

Allergies:

  • “Do you have any allergies?”

 


Social history

Smoking: 

  • How many cigarettes a day?
  • How long have they smoked for?

 

Alcohol:

  • How many units a week?
  • Clarify the type, volume and strength of the alcohol

 

Recreational drugs:

  • Clarify the types of recreational drugs used
  • IV drug administration and sharing of the equipment used to snort cocaine increases the risk of acquiring blood-borne viruses such as Hepatitis C and HIV

Also consider if it is appropriate to ask the age of partner(s), and be aware of safeguarding issues, especially surrounding the social factors related to sexual encounters.

 


HIV risk history

Identify if positive risk factors are present:

  • “Have you ever had a partner who is known to be HIV positive?”
  • “Have you ever had sex with a bisexual man/engaged in male homosexual activity?”
  • “Have you ever had sex with someone abroad, or who was born in a different country?”
  • “Have you ever injected drugs?”
  • “Are you aware of any of your previous partners having ever injected drugs?”
  • “Have you ever paid someone for sex, or been paid for sex?” 

 


Closing the consultation

Summarise the history if appropriate

Ask if the patient has any questions

Re-affirm confidentiality, or discuss if any breaches are felt to be appropriate

Thank the patient

 


 

Assessment

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