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Sexual health. If you’re embarrassed and choking up and looking at your feet, how do you expect your patient to feel?

Sexual history taking is something many of you fear, so here is a quick template of what to ask, and some suggestions of how to go about asking! Hetero-, homo-, group, trans* and gender issues – sensitivity and openness is key!

If you know it’s something that makes you awkward, or you have problems with the “poker face” or asking about sex toys, anal sex, group sex, types of sex then practice asking the questions! Practice in the mirror, practice asking your cat, practice asking your teddy bears! Practice makes perfect (or less awkward…).

Clarify 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. Be aware of the array of social issues which you may come across (age of patient/partner(s), alcohol or drug intoxication, consent).

Check out the sexual history taking mark scheme here.



Opening the consultation

Introduce yourself – name/role

Confirm patient’s details– name/date of birth

Explanation/consent:

I’ve been asked to take a sexual history from you, this is going to involve me asking some personal questions which you may find uncomfortable. Everything you tell me is confidential within the boundaries of the team looking after your care. If you would like to stop at any time, please let me know.”


Presenting complaint

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

“So what’s brought you in today?”   or  “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

For each of the symptoms below ensure you clarify duration/severity/course (worsening vs improving)/exacerbating and relieving factors.

Vaginal discharge: itchy/offensive – different to normal?

“Have you noticed any discharge? Does it smell? What does it look like?”

 

Dysuria / frequency

“Do you have any pain when passing urine? Do you feel you are going more often?”

 

Vulval itching/soreness

“Do you have any itching/soreness down below?”

 

Genital skin changes

“Have you noticed any skin changes around your vagina?”

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

 

Abdominal pain – SOCRATES is useful here

“Have you had any pain in your tummy?”

“Where in the tummy is the pain?”

“Does it move anywhere else?”

 

Pain during or after intercourse – dyspareunia 

“Do you ever experience any pain around the time of sex?”

“Does the pain feel to be within the vagina, or deep in your stomach?”

“When does it occur? How long does it last?”  (before/during/after)

 

Systemic symptoms (which may be related)

“Have you noticed any rashes elsewhere on your body?”

“Do you have any pain in your joints?” – reactive arthritis (e.g. chlamydia)

“Have you had any pain in your eyes?” – iritis / anterior uveitis 

Menstrual history

Last menstrual period (LMP) “When was your last period?”

Regularity – monthly / unpredictable  – “Do you have regular periods?”

Length of cycle –  “How long is your cycle? / How long do you bleed for?”

Dysmenorrhoea – “Any problems with pain or heavy bleeding during periods?” (new vs longstanding)

Post-coital bleeding – “Do you experience any bleeding after sexual intercourse?” (new vs longstanding)

Intermenstrual bleeding – “Do you have episodes of bleeding between periods?” (new vs longstanding)

Gynae history

Cervical screening (previously smear) – dates / results

“Have you recently undergone cervical screening (smear)? When? What were the results?”
“Have you ever had an abnormal result?”     

Treatment – previous gynaecological treatment – e.g. loop excision of transitional zone (LETZ)

“Have you had any previous treatment to your cervix?”

Obstetric history

Contraception – type of contraception / length of use / any issues / previous contraception

“What do you use for contraception at the moment?”

Current pregnancy? – “Are you or do you think you may be pregnant at the moment?”


Things to ask people with a penis

Pain in testes/scrotum

“Have you noticed any pain in your groin/testicles/penis?”

 

Swellings

“Have you noticed any swellings or change in size of your testicles?”

 

Itching or sore skin

Have you noticed any itching genitally?”
“Is the skin around your penis/testicles sore?”

 

Skin changes – genital and elsewhere

“Have you noticed any redness around your genitals?”

“Have you noticed any lumps, bumps or ulcers around your penis/testicles/anus?”

 

Discharge from the urethra

Have you noticed any discharge from your penis?”

 

Dysuria (including frequency, urgency, nocturia)

“Do you have any pain or burning in your genitals or your stomach when you pass urine?”

“Do you feel you are passing urine more often?”

“Is there any blood in your urine?”

 

Systemic symptoms which may be related

“Have you noticed any rashes elsewhere on your body?”

“Do you have any pain in your joints?”

“Have you had any pain in your eyes?”


Sexual history: Last sexual contact

Sign-posting here is of benefit to ensure the patient (and yourself!) are prepared for the nature of the questions surrounding the specific sexual health aspect.

“Next, I’m going to move on to discuss your sexual history. Some of these questions are sensitive and can make people feel embarrassed. It’s important for me to find out this information though, so we can assess the risk of you being in contact with a sexually transmitted infection, and any others involved.”

 

Timing of last sexual contact

“When did you last have a sexual encounter?”

 

Consensual?

 

Partner demographics

“What sex was the partner in question?”

 

Types of sex involved – oral (genital and anal) / anal / vaginal /digital

For oral / anal sex, clarify if the patient gave or received it (or both)

“What was involved in this encounter?” 

“Was there more than one other person involved?”

 

Contraception used – condoms / dental dams / etc

Clarify if contraception was used for all sexual encounters or only a subset.

Ask if there were any problems with contraception at any point – e.g. condom splitting

“Was there any point at which contraception was not used during the sex?”

“Was there any issues with the contraception used?”

 

Other 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 / Surgical history

“Now I’m going to move on and ask some questions about your general health.”

Previous sexually transmitted infections (including partners)

Medical/surgical problems

“Is there anything you see the doctor regularly for?”

“Have you been in hospital for anything in the past?”


Drug history

Current medications

Recent antibiotics

ALLERGIES


Social history

Smoking – How many cigarettes do they smoke a day? / How many years have they smoked for?

Alcohol – How many units a week? – Be specific about type / volume / strength of alcohol

Recreational drug use – IV drug use is a risk factor for Hepatitis / HIV

“Have you ever taken any other drugs?”

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 whom 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 history if appropriate

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

Thank patient