Taking a sexual history is something medical students and doctors can find difficult. As a result, we’ve created a sexual history taking guide which helps explain which questions need to be asked, and how best to phrase them to the patient.
If you know it’s something that makes you awkward, or you have problems 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!
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. Be aware of the array of social issues which you may come across (age of patient/partner(s), alcohol or drug intoxication, partner notification, consent).
Opening the consultation
Introduce yourself (explaining your name and role)
Confirm the patient’s details (name and date of birth)
“I’ve been asked to take a sexual history from you, this is going to involve me asking some personal questions which can make some people feel uncomfortable. We ask the same questions to everyone to allow us to accurately assess their risk of sexually transmitted infections, so please don’t take any 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.”
“Are you happy for me to ask you some more questions?”
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
Key questions to ask about each symptom
If any of the symptoms below 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?”
- 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?”
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?”
- Smell – “Have you noticed any offensive smell from the discharge?”
- Gonorrhoea and chlamydia commonly present with abnormal vaginal discharge
- Trichomonas vaginalis typically presents with yellow frothy discharge with associated vaginal itching and irritation
- Bacterial vaginosis typically presents with an offensive, fishy-smelling vaginal discharge, without any associated soreness or irritation
Abnormal vaginal bleeding is an important symptom that can be relevant to a wide range of gynaecological disease.
- Vaginal bleeding occurring after sexual intercourse
- Causes include infection (e.g. chlamydia and gonorrhoea), cervical ectropion and cervical cancer
- Vaginal bleeding occurring between menstrual periods
- 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
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:
- Duration of the symptom
- Location of the pain (e.g. superficial or deep)
- Nature of the pain (e.g. sharp, aching, burning)
- “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)
Urinary symptoms (dysuria, frequency)
- “Do you have any pain when passing urine?”
- “Do you feel you are going more often?”
Vulval itching and soreness are common symptoms which can have several underlying causes including:
- Candida (thrush)
- Bacterial vaginosis
- Genital herpes
- 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
- “Do you have any itching/soreness down below?”
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.
- “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
The acronym SOCRATES provides a useful framework for asking about pain, as shown below.
- Where is the pain?
- When did it start?
- Was the onset sudden or gradual?
- Is the pain sharp or a dull ache?
- Is the pain intermittent or continuous?
- Does the pain radiate anywhere?
- Are there any other symptoms associated with the pain?
- 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?
- 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?
Sexually transmitted infections can also cause systemic symptoms:
- Fever (secondary to pelvic inflammatory disease)
- Weight loss (e.g. HIV)
- Swelling of large joints, conjunctivitis and cervicitis (Reiter’s syndrome secondary to chlamydia)
- “Have you noticed any rashes elsewhere on your body?”
- “Do you have any swelling or pain in your joints?”
- “Have you had any eye discomfort?”
A menstrual history involves clarifying the details of a woman’s menstrual cycle.
Menstrual cycle details
- Average duration is 5 days
- More than 7 days would be considered prolonged
- “How long do your periods typically last?”
- The average is 28 days
- “How often do your periods happen?”
- “Are they regular and predictable?”
Menstrual blood flow:
- This is an assessment of the volume of menstrual bleeding
- 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
- “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?”
Past gynaecological history
Cervical screening (known previously as a 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
- Malignancy (e.g. cervical, endometrial, ovarian)
Current pregnancy (if relevant):
- 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
Pain in testes/scrotum
“Have you noticed any pain in your groin/testicles/penis?”
“Have you noticed any swellings or change in the size of your testicles?”
Itching or sore skin
“Have you noticed any itching around your genitals?”
“Is the skin around your penis/testicles sore?”
Skin changes (anogenital region)
“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?”
“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 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 sensitive and can make people feel embarrassed. It’s important for me to find out this information, so we can assess the risk of you being in contact with a sexually transmitted infection. We ask the same questions to everyone, so please don’t take anything personally.”
Timing of the last sexual contact
“When did you last have a sexual encounter?”
“Was this sexual encounter consensual?”
“What sex was the partner in question?”
“What country was the partner from?”
Types of sex involved
- Oral (genital and anal)
- Anal – clarify if the patient gave or received (or both)
- “What was involved in this encounter?”
- “Was there more than one other person involved?”
Clarify if contraception was used for all sexual encounters or only a subset.
Clarify the type of contraception used:
- Male condoms
- Female condoms
- Dental dam
- Hormonal contraceptives
“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?”
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
“Now I’m going to move on and ask some questions about your general health.”
Previous sexually transmitted infections (including partners)
“Is there anything you see the doctor regularly for?”
“Have you been in a hospital for anything in the past?”
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 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 history if appropriate
Re-affirm confidentiality, or discuss if any breaches are felt to be appropriate