Taking a Sexual History

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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).

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Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

“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 to proceed with history taking.

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Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

• “What’s brought you in to see me today?”
• “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

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

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

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Things to ask people with a vagina

Once the patient has had time to communicate their presenting complaint, you should then begin to explore the issue with further open and closed questions.

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.

Site

Ask about the location of the symptom:

• “Where is the pain?”
• “Can you point to where you experience the pain?”

Onset

Clarify how and when the symptom developed:

• “Did the pain come on suddenly or gradually?”
• “When did the pain first start?”
• “How long have you been experiencing the pain?”

Character

Ask about the specific characteristics of the symptom:

• “How would you describe the pain?” (e.g. dull ache, throbbing, sharp)
• “Is the pain constant or does it come and go?”

Radiation

Ask if the symptom moves anywhere else:

• “Does the pain spread elsewhere?” (e.g. shoulder tip pain in ectopic pregnancy)

Associations

Ask if there are other symptoms which are associated with the primary symptom:

• “Are there any other symptoms that seem associated with the pain?” (e.g. abnormal vaginal discharge in gonorrhoea)

Time course

Clarify how the symptom has changed over time:

• “How has the pain changed over time?”

Ask if the symptom has any relationship to the menstrual cycle:

• “Have you noticed if this symptom is worse at a particular time in the month?”

Exacerbating or relieving factors

Ask if anything makes the symptom worse or better:

• “Does anything make the pain worse?”
• “Does anything make the pain better?”

Severity

Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:

• “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?”

Ask the patient if the symptom is having a significant impact on their day to day life:

• “How is the pain impacting your daily life?”

Key symptoms

Once you have completed exploring the history of presenting complaint, you need to move on to more focused questioning relevant to people with a vagina.

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.

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

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 varies between patients:

• 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 duration of the symptom
• the location of the pain (e.g. superficial or deep)
• the nature of the pain (e.g. sharp, aching, burning)

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)
• 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 infections including:

• Genital herpes: painful crops of blisters/ulcers affecting the 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 ectopic pregnancy. The acronym SOCRATES (shown above) is useful for exploring abdominal and pelvic pain.

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  (reactive arthritis 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 exploring the characteristics of the patient’s menstrual cycle.

Duration

Ask the patient about the duration of their periods:

• “How long do your periods typically last?”

The average duration of menstruation is 5 days, with more than 7 days considered prolonged.

Frequency

Ask the patient about the frequency of their periods:

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

Periods typically occur every 28 days, however, there is significant variation between individuals (21-40 days).

Menstrual blood flow

Ask the patient about the volume of their periods:

• “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?”
• “Are the heavy periods impacting your day to day life?”

The average menstrual blood loss is approximately 40mls (8 teaspoons). Heavy menstrual blood loss is defined as more than 80mls (16 teaspoons) or having periods that last longer than 7 days.

The definition of what is a “heavy period” compared to a “normal period” is highly subjective, therefore you should ask the woman how the current periods compare to her usual loss. If the volume of bleeding is impacting on the woman’s day to day life, it is significant.

Past gynaecological history

It is important to ask about a woman’s previous gynaecological history, as this may influence further investigations and management options.

Gynaecological conditions

Ask if the patient has previously had any gynaecological problems:

• Ectopic pregnancy
• Sexually transmitted infections
• Endometriosis
• Bartholin’s cyst
• Cervical ectropion
• Malignancy (e.g. cervical, endometrial, ovarian)

Gynaecological surgery or procedures

Ask the patient if they’ve previously undergone any surgery or procedures in the past such as:

• Abdominal or pelvic surgery
• Caesarean section
• Loop excision of the transitional zone (LETZ)
• Vaginal prolapse repair
• Hysterectomy

Cervical screening

Clarify the patient’s cervical screening history:

• Confirm the date and result of the last cervical screening test.
• Ask if the patient received any treatment (if the cervical screening test was abnormal) and ask if follow up is in place.
• Ask if the patient has been vaccinated against HPV.

Obstetric history

It is important to take a brief obstetric history as part of a sexual history, as it may be relevant to the patient’s presentation and may influence management decisions. This is less detailed than a focused obstetric history.

Gravidity and parity

Gravidity is the number of times a woman has been pregnant, regardless of the outcome.

Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).

Current pregnancy

Gather key details about the patient’s current pregnancy (if relevant):

• Gestation
• Symptoms associated with pregnancy (e.g. nausea, vomiting, back pain)
• Complications (e.g. pre-eclampsia, cervical neck incompetence)
• Recent scans results

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Things to ask people with a penis

The presenting complaints of people with a penis can be initially explored using questions from the SOCRATES acronym explained earlier in the guide.

Key symptoms

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

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

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 
• Malaise
• Weight loss (e.g. HIV)
• Rash
• Swelling of large joints (reactive arthritis secondary to chlamydia), conjunctivitis

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?”

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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:

• “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?”
• “Did you take drugs just before or during sex?”
• “Did the sex involve more than two people?”

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 questions for each

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HIV risk assessment

Ask specifically about HIV risk factors to determine the patient’s risk profile:

• “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?” 

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Past medical and surgical history

It is important to ask about the patient’s medical history, as these conditions may impact the sexual health issue and may themselves be impacted by or prevent the use of specific treatments.

Ask if the patient has any medical conditions: 

• “Do you have any medical conditions?”
• “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Ask if the patient or any of their sexual partners have previously been diagnosed with a sexually transmitted infection.

Explore which immunisations the patient has previously received:

• Hepatitis A/B and HPV vaccinations are particularly relevant to men who have sex with men.

Allergies

It’s essential to clarify any allergies the patient may have and to document these clearly in the notes, including the type of allergic reaction the patient experienced.

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Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

• “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

• “Have you noticed any side effects from the medication you currently take?”

Some medications may cause sexual health issues or interfere with medications:

• St John’s Wart increases the metabolism of the COCP reducing its effectiveness.
• Antibiotics may cause secondary vaginal thrush.

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Social history

Understanding the social context of a patient is absolutely key to building a complete picture of their health.

General social context

Explore the patient’s general social context including:

• who else the patient lives with and their personal support network
•  the age of partner(s): be aware of safeguarding issues, especially surrounding the social factors related to sexual encounters

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Consider if medications such as the COCP are contraindicated because of the patients smoking status:

• If smoking more than 40 cigarettes a day, the COCP would be contraindicated.
• If over 35-years-old and smoking more than 15 cigarettes a day, the COCP would be contraindicated.

Alcohol

Record the frequency, type and volume of alcohol consumed on a weekly basis (see our alcohol history taking guide for more information).

The use of alcohol may impair a patient’s ability to recall important details of sexual encounters (e.g. use of contraception).

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.

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.

The use of recreational drugs may impair a patient’s ability to recall important details of sexual encounters (e.g. use of contraception).

Diet and weight

Ask if the patient what their diet looks like on an average day.

Ask about the patient’s current weight:

• Anorexia can result in oligomenorrhoea (infrequent periods) or amenorrhoea (absence of menstruation).
• A raised BMI may be a contraindication to some treatments, including combined oral contraceptives.

Occupation

Ask about the patient’s current occupation and if they are managing ok at work with their current symptoms.

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Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

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

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

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