Taking a Sexual History

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The ability to take a thorough sexual health history is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a sexual history in an OSCE setting.

Patients often feel embarrassed when discussing their sexual health. They may minimise symptoms or delay seeking medical care. To deliver the best possible inclusive care for our patients, we need to feel comfortable asking questions regarding sexual health.

Terminology in sexual health can sometimes be challenging for students. Patients may use colloquial terms or vague language, and it is important always to clarify what the patient means to avoid misunderstandings. For example,  “sex” is not synonymous with penetration and could take several forms for the patient. You should be able to obtain a thorough and accurate history without using innuendos!

Taking a sexual history involves more than identifying symptoms. You must also consider:

  • Confidentiality: this is especially important when taking a sexual health history to build trust with the patient
  • Safeguarding: identifying any safeguarding concerns (e.g. suicide risk or sexual violence)
  • Risk-taking behaviours: sexually transmitted infections (e.g. HIV), recreational drug use
  • Prevention of onward transmission: potential exposed partners, partner notification

Above all else, taking a good sexual health history requires excellent communication skills to build trust and rapport with the patient.


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 the confidential nature of the consultation: Everything we discuss during this consultation is kept confidential between our healthcare team taking care of you unless you say something that makes me concerned about the safety of yourself or others. If, in this event, I would need to break your confidentiality, I would make every effort to tell you first.

Explain that you’d like to take a history from the patient: “Today, I need to ask you some personal questions about your sexual health. We ask these questions to assess your risk of sexually transmitted infections. Please let me know if you would prefer not to answer a particular question or stop the consultation at any point. Sometimes there are some preferred words or terms people would like to refer to their genitals or words they would rather us not use. Do you have any preference?

Gain consent to proceed with history taking.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal.
  • Active listening: through body language and your verbal responses to what the patient has said.
  • An appropriate level of eye contact throughout the consultation.
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
  • Making sure not to interrupt the patient throughout the consultation.
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat).
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
  • Summarising at regular intervals.
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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?”
Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.


History of presenting complaint

Vaginal symptoms

We have included a focused list of vaginal symptoms with relevant background information. 

Vaginal symptoms and causes

Vaginal discharge

It is important to distinguish between normal and abnormal vaginal discharge.

Vaginal discharge is normal and often varies across a menstrual cycle. This pattern can indicate a ”fertile window” for those using a natural family planning contraceptive method. 

However, any change in vaginal discharge is relevant and important to clarify as this can indicate pathology.

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. For more information, see the Geeky Medics guide to sexually transmitted infections.

Vaginal bleeding

Abnormal vaginal bleeding is an important symptom relevant to a wide range of gynaecological conditions. With all vaginal bleeding, it is important to clarify the following:

  • Nature and pattern of the bleeding (e.g. post-coital, intermenstrual)
  • Volume (spotting, soaking through pads)
  • Colour (bright red vs dark)
  • Impact on quality of life

Post-coital bleeding refers to vaginal bleeding occurring after sexual intercourse:

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

Intermenstrual bleeding refers to vaginal bleeding occurring between menstrual periods:

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

Dyspareunia

Dyspareunia refers to pain that occurs during sexual intercourse.

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 sexually transmitted infections and pelvic inflammatory disease)

You should clarify:

  • Duration of the symptom
  • Location of the pain (e.g. superficial or deep)
  • Nature of the pain (e.g. sharp, aching, burning)

Abdominal and pelvic pain

Abdominal and pelvic pain is a broad symptom associated with various conditions. Use SOCRATES to establish an accurate pain history and narrow the list of potential causes.

The nature of the pain can indicate the underlying cause:

  • Dysuria (pain when urinating): most often caused by a urinary tract infection, which could be a sexually transmitted infection
  • Abdominal pain with shoulder tip pain: typical of a ruptured ectopic pregnancy
  • Constant cramping pelvic pain: pelvic inflammatory disease

Vulval skin changes/itching/lesions

Vulval skin changes will require a clinical examination to assess the lesion (s) accurately. Vulval itching, soreness or lesions can indicate a genital skin infection (e.g. folliculitis), a sexually transmitted infection (e.g. genital herpes) or a dermatological condition (e.g. contact dermatitis, lichen sclerosis). During the history, clarify the location and if any lesions are painful or non-painful, as this can indicate the underlying pathology:

  • “Have you noticed any skin changes?”
  • “Have you noticed any lumps, bumps or rashes? Are these painful?”

You should clarify:

  • Timing of the symptom: “When does the itching occur? Is it worse at night?”
  • Episodic vs constant: “Is it always there, or does it come and go?”
  • Skin irritants: “Do you use any shower gels or cleaning products? Have you changed your washing powder recently?

Menstrual history

A menstrual history involves exploring the characteristics of the patient’s menstrual cycle. This section can be omitted in patients who do not have a uterus or who have gone through menopause.

In a sexual health history, the key points to establish are:

  • Date of last menstrual period (LMP)
  • Cycle length (i.e., how long from day 1 of bleeding until the next episode of bleeding)
  • Cycle regularity (i.e., is the cycle duration consistent or variable)

Ask the patient when the first day of their last menstrual period was:

  • “What date was the first day of your last menstrual period?”

Ask the patient about the length and regularity of their menstrual cycle:

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

Periods typically occur every 28 days. However, there is significant variation between individuals.

Pregnancy testing

If the patient’s period is late, offer to perform a pregnancy test. This may influence management and is particularly important in patients with abdominal pain (to exclude ectopic pregnancy).

Gynaecological history

Previous gynaecological history may influence investigations and management of sexually transmitted infections. 

Ask if the patient has previously had any gynaecological problems:

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

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

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 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 sexual history taking, as it may be relevant to the patient’s presentation and may influence management decisions. This is less detailed than a focused obstetric history.

If the patient is pregnant, clarify the gestation, planned mode of delivery and any obstetric concerns

Penile symptoms

We have included a focused list of penile symptoms with relevant background information. 

Penile symptoms and causes

Urethral discharge

It is important to distinguish between normal and abnormal penile discharge. A small amount of clear discharge at the meatus can be normal.

Clarify the characteristics of the discharge:

  • Colour (e.g. green, yellow or blood-stained): “What colour is the discharge you’ve noticed?”
  • Consistency (e.g. thickened or watery): “Is the discharge thick or thin and watery?”
  • Volume/frequency: “Are you constantly having to wipe away the discharge, or does it come and go?”

Several STIs can cause urethral discharge. For more information, see the Geeky Medics guide to sexually transmitted infections.

Dysuria

Dysuria can be a symptom of a sexually transmitted or non-sexually transmitted urethral infection (UTI):

  • “Do you have any burning or stinging in your penis when you pass water”

In young patients, penile dysuria is more likely to be caused by a sexually transmitted infection than in older patients. 

Dysuria may be associated with urinary frequency and haematuria:

  • “Do you feel you are passing urine more often?”
  • “Is there any blood in your urine?”

Testicular pain and/or swelling

Testicular pain and swelling may suggest epididymo-orchitis (inflammation and pain of the epididymis and/or testes): 

  • “Have you noticed any pain or swelling in your testicles?”
  • “Have you noticed any lumps or swellings in the scrotum?”

If pain or swelling is present, explore this further using SOCRATES.

Testicular torsion

Acute onset unilateral testicular pain is a red flag for testicular torsion, a surgical emergency requiring urgent surgical review

Penile skin changes/itching/lesions

Penile skin changes will require a clinical examination to accurately assess the lesion(s). Penile itching, soreness or lesions can indicate a genital skin infection (e.g. candidiasis), a sexually transmitted infection (e.g. genital herpes) or a dermatological condition (e.g. contact dermatitis, lichen sclerosis).

During the history, clarify the location and if any lesions are painful or non-painful, as this can indicate the underlying pathology:

  • “Have you noticed any skin changes?”
  • “Have you noticed any lumps, bumps or rashes? Are these painful?”

You should clarify:

  • Timing of the symptom: “When does the itching occur? Is it worse at night?”
  • Episodic vs constant: “Is it always there, or does it come and go?”
  • Skin irritants: “Do you use any shower gels or cleaning products? Have you changed your washing powder recently?

Penile swelling

Inflammation of the penis is called balanitis and can be due to infection (e.g. sexually transmitted infection) or dermatological conditions (e.g. lichen sclerosus, Zoon’s balanitis). This inflammation can lead to swelling of the glans, penis and foreskin (if present).

  • “Do you have any swelling of the penis?”

Balanitis can lead to paraphimosis, where the foreskin cannot be replaced over the glans. This could compromise the blood supply to the penis and requires urgent review. 

  • “Are you able to retract and replace your foreskin?”

Abdominal and pelvic pain

Abdominal and pelvic pain may suggest prostatitis or a urinary tract infection

Rectal symptoms

Asking about rectal symptoms is an important component of the sexual history, as patients may not routinely disclose these symptoms. Most sexually transmitted infections can affect the rectum, but their presence does not necessarily mean anal penetration has occurred.

We have included a focused list of rectal symptoms with relevant background information. 

Rectal symptoms and causes
  • Rectal discharge: sexually transmitted infection, foreign body, inflammatory bowel disease, malignancy
  • Rectal pain: anal fissure, proctitis (inflammation of the rectal lining), haemorrhoids
  • Rectal lump: haemorrhoids, genital warts, malignancy
  • Anal skin changes/itching/lesions: genital warts, genital herpes, lichen sclerosus, syphilis (chancre), threadworm, anal cancer

Rectal discharge

Rectal discharge is abnormal and should prompt further questioning if disclosed.

Clarify the characteristics of the discharge:

  • Colour (e.g. green, yellow or blood-stained): “What colour is the discharge you’ve noticed?”
  • Consistency (e.g. thickened or watery): “Is the discharge thick or thin and watery?”
  • Volume/frequency: “Are you constantly having to wipe away the discharge, or does it come and go?” “Is it mixed in with stool?”

Several STIs can cause rectal discharge. For more information, see the Geeky Medics guide to sexually transmitted infections.

Rectal pain

Rectal pain may arise as a result of an anal fissure or haemorrhoid. However, it may also be a sign of proctitis; inflammation of the rectum. Proctitis can be due to a sexually transmitted infection.

  • “Do you have any pain arising from the back passage?”
  • “Is it painful to open your bowels?”

Rectal lump

Most causes of rectal lumps are benign (e.g. genital warts and haemorrhoids). However, it is important not to miss a malignancy and an examination should be offered. 

Anal skin changes/itching/lesions

Anal skin changes will require a clinical examination to assess the lesion(s) accurately. Itching or soreness can indicate an anogenital skin infection (e.g. folliculitis, scabies), a sexually transmitted infection (e.g. genital herpes) or a dermatological condition (e.g. contact dermatitis, lichen sclerosis). Other causes are haemorrhoids, fissures and threadworm.

During the history, clarify the location and if any lesions are painful or non-painful, as this can indicate the underlying pathology:

  • “Have you noticed any skin changes?”
  • “Have you noticed any lumps, bumps or rashes? Are these painful or itchy?”
  • “Have you noticed any tingling or burning in the area of the lesions?”

You should clarify:

  • Timing of the symptom: “When does the itching occur? Is it worse at night?”
  • Episodic vs constant: “Is it always there, or does it come and go?”
  • Skin irritants: “Do you use any shower gels or cleaning products? Have you changed your washing powder recently?”

Oral symptoms

Sexually transmitted infections can also be transmitted to the oral cavity and infect the pharynx. Symptoms can include a sore throat (e.g. gonorrhoea) or ulcer(s) (e.g. HSV, chancre).

It is important to ask about oral sex during the sexual history, as pharyngeal swabs may be appropriate. However, most sore throats are not due to a sexually transmitted infection!

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideasconcerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more naturalpatient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’s ideas about the current issue:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought, and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”
  • “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far“Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next“Next I’d like to quickly screen for any other symptoms and then ask some questions about your sexual partners. Would this be okay?”


Systemic enquiry

systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Sexually transmitted infections can cause systemic symptoms such as:

  • Fever (secondary to pelvic inflammatory disease)
  • Malaise
  • Weight loss (e.g. HIV)
  • Rash
  • Swelling and tenderness of large joints, conjunctivitis (reactive arthritis secondary to chlamydia)

Last sexual contact

Signposting here is beneficial to ensure the patient is prepared for 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. Just let me know if you feel uncomfortable and would prefer not to answer.”

Timing

Ask about the timing of the last sexual contact:

  • “When was the last time you had any sexual contact?”

Sexual contact

You should clarify the nature of the sexual contact to establish which anatomical sites will require testing. Establishing if a barrier method was used is important to assess the risk of STI transmission and to ascertain if emergency contraception is required (if penile-vaginal penetration occurred). 

  • “What type of sex did you have with them?”
  • “Did you give or receive vaginal/frontal sex?”
  • “Did you give or receive anal sex?”
  • “Did you give or receive oral sex?”
  • “Did you use any sex toys?”
  • “Was a condom or dental dam used?”
  • “Were you having sex as part of a group?”

Relationship

Ask if this was a regular sexual partner or a one-off casual sexual encounter and how long they have been having sex with them. This will help establish if they are outside the window periods (appropriate time to test) for testing:

  • “Was this a regular sexual partner or a casual sexual encounter?”
  • “How long have you been having sex with this partner?”

Contraception

Clarify the method of contraception used (if any) and the consistency of usage if penile-vaginal penetration has occurred:

  • “Were you or your partner using any contraception during this contact?”
  • “Did you have any problems using contraception during sex (e.g. condom split or pill forgotten)?”
  • “Was there any point at which contraception was not used during sex?”

Other sexual partners

Ask about other sexual partners in the last three months:

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

STI testing history

Ask the patient when their last sexual health screen was and if they or any of their partners have previously been diagnosed with a sexually transmitted infection.

  • “When was your last sexual health screen?”
  • “Have you been diagnosed with a sexually transmitted infection before? If so, which one and how was it treated?”
  • “Have any of your sexual partners been diagnosed with a sexually transmitted infection?”

Sexual violence

It is important in a sexual history to screen for sexual violence so appropriate screening, post-exposure prophylaxis (if applicable), signposting, and support can be provided:

  • “Do you feel safe with your current partner?”
  • “Any violence towards you in this relationship?”
  • “Have you ever had sex that you’ve not consented to?”
  • “Have you ever had any procedures to your genitals for non-medical purposes such as cutting, piercing or burning?”
Female genital mutilation

The World Health Organisation defines female genital mutilation as “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons”.  Performing or assisting someone to perform FGM is illegal in the United Kingdom. 

For more information, see the NHS page on female genital mutilation.

Other safeguarding issues

In a sexual health history, it is important to identify any other safeguarding issues, including:

  • Age of the sexual partner (if the patient is under 18)
  • Recreational drug use
  • Power imbalance
  • Contact with social services

Blood borne virus risk assessment

Blood borne sexually transmitted infections include syphilis, HIV and some types of hepatitis. It is important to ask about risk factors for blood borne viruses to determine the patient’s risk. Risk factors for blood borne viruses include:

  • Partners from countries where HIV and hepatitis viruses have a high prevalence
  • Sex between cisgender men or transgender woman
  • Current or past use of injecting drugs
  • Recreational drug use during sex
  • Sex with someone living with HIV (if they don’t have an undetectable viral load) or hepatitis?
  • Sex work
  • Sex with more than >10 partners in 12 months
  • Post-sexual assault

Example questions to ask to assess risk:

  • “When was your last blood test for HIV and syphilis?”
  • “Have any of your partners been from abroad or were born abroad?”
  • “Have you ever had a partner known to be HIV positive?”
  • “Have you ever injected any recreational drugs?”
  • “Have you ever used any recreational drugs during sex?”
  • “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?” 
  • “Have you ever had any sex you’ve not consented to?”

Explore which immunisations the patient has previously received:

Ask if the patient has been taking pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) to prevent HIV acquisition.


Past medical history

It is important to ask about the patient’s medical history, as this may influence the investigation, diagnosis and/or management of a sexually transmitted infection.

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.

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).


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 namedosefrequencyform and route.

Examples of relevant medications

Some examples of medications relevant to a sexual health history include:

  • PrEP and PEP: used to prevent HIV acquisition
  • Antiretrovirals: used to treat HIV and some forms of hepatitis
  • Antivirals (e.g. aciclovir): used for the suppression of herpes simplex virus
  • Antibiotics: can cause candidiasis (thrush)
  • SGLT2 inhibitors (e.g. dapagliflozin): can increase the risk of candidiasis 

Social history

Most of the social history will have already been explored in the sections above (e.g. recreational drug use), and you may not need to ask all the questions in this section. 

Smoking

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

Smoking can make it more difficult to treat genital warts.

See our smoking cessation guide for more details.

Alcohol

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

Some medications used to treat sexually transmitted infections (e.g. metronidazole) should not be taken with alcohol. 

Offer support services to assist the patient in reducing their alcohol intake.

Sexual problems

Patients presenting to a sexual health clinic may have an underlying problem or difficulty during sex, which they may not disclose for fear of embarrassment (e.g. premature ejaculation, erectile dysfunction, dyspareunia, low libido or anorgasmia).

Some of these problems may have associated underlying organic pathology (e.g. erectile dysfunction is associated with atherosclerosis), and are important to identify and treat. 

Depending on the patient’s presentation, it may be appropriate to ask about sexual problems:

  • “Sometimes people experience problems during sex. Do you have any problems or concerns we haven’t discussed so far?”

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.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


References

  1. British Association for Sexual Health and HIV. UK National Guideline for consultations requiring sexual history taking: Clinical Effectiveness Group. Published in 2019. Available from: [LINK]
  2. World Health Organization. Female genital mutilation. Published in 2023. Available from: [LINK]
  3. NHS. Female genital mutilation (FGM). Published in 2022. Available from: [LINK]

 

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