Get Guideline Alerts Direct to Your Phone
Sexual History Taking 101: How Do I Start the Conversation with my Patients? image

Sexual History Taking 101: How Do I Start the Conversation with my Patients?

Review the latest recommendations with

David Malebranche, MD, MPH and Ariel Watriss, MSN, NP-C

Dr. Malebranche (he/him/his), an internal medicine specialist with expertise in sexual health and HIV/STI prevention and treatment, is a clinician at the AIDS Healthcare Foundation Health Care Center in midtown Atlanta

Ariel Watriss (she/her/hers) is a college health nurse practitioner at Tufts University in Boston, and a renowned sexual health clinician and educator

Learning Objectives:

  • Define sexual health and how it is applied in clinical settings
  • Detail the burden of sexually transmitted infections (STI) in the United States
  • Describe standardized guidelines to sexual history-taking
  • Identify affirming approaches to successful sexual history-taking

CONTENTS:

THE CASE:

A 34-year-old cis-woman comes to your office for a routine check-up and STI screening. She is asymptomatic and denies any genitourinary symptoms or concerns.

  • She married at a younger age and is now divorced. She has two young children and is taking her first steps towards returning to the dating world and sexual activity. She wants to discuss options where she can enjoy sex again but can also empower herself with tailored approaches to STI and HIV prevention
  • She has always been attracted to both men and women, but only had sex with her husband for the 10 years they were married. She is open to either gender for a sexual relationship moving forward
  • She has no medical conditions and is currently not taking any medications. She would consider condoms and birth control for contraception, but is interested in what may work best for her

Overview of Taking a Sexual History

The sexual history is a vital, yet often overlooked aspect of the clinical history and physical in medical settings

  • Topics regarding sexuality, sexual orientation and behavior, and gender identity are vital aspects of the social history that can direct providers to identify
    • sexual health and wellness recommendations
    • screening tests
    • tailored HIV and STI prevention approaches
  • When it comes to HIV pre-exposure prophylaxis, or “PrEP,” it is impossible to hold a fluent conversation about HIV prevention before first becoming proficient in talking about sex

Defining and Centering Sexual Health

The definition of sexual health has been debated and modified over the years, but most sexual health experts refer to the World Health Organization (WHO) definition:

“Sexual health is fundamental to the overall health and well-being of individuals, couples and families, and to the social and economic development of communities and countries. Sexual health, when viewed affirmatively, requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.”

  •  In many health professional schools, students have historically been taught to address sex from a pathological framework centered on disease states (i.e., HIV and STIs), screening for these conditions, and treating them appropriately
  • Today’s approach to STI and HIV prevention and treatment now is proactive, focusing instead on sexual health, wellness, and prevention by creating spaces where patients feel more comfortable discussing their full and authentic selves
  • Most people receiving new HIV diagnoses report contracting it through sexual transmission | To reduce the continued burden of STI and HIV rates, eliciting a good sexual history is crucial

The Context of Taking A Sexual History in Clinical Settings

When beginning as sexual history, it is important to recognize the complex dynamics that take place within the patient-clinician encounter:

  • Patients prefer active inquiry about sexual health issues from clinicians (Ryan et al., 2018)
  • Generational differences matter in communication about sexual health (Rabathaly and Chattu, 2019)
  • Providers’ perception of how sexual history questions will be received by patients influences if a sexual history will be elicited and perceived competence led to more frequent screening (Tong et al., 2013)
  • Sexual history-taking education in medical school curricula shows promise in improving students’ confidence in and comfort with conducting sexual histories with their patients (Bourne et al., 2020)

Competing interests and within-clinic demands also contribute to difficulty with competency in sexual history taking on a visit-by-visit basis:

  • Not having enough time to discuss sensitive sexual information in a 15-minute clinical visit
  • Building trust quickly without offending with personal questions
  • Competing clinical priorities – chief complaint, other medical issues, health care maintenance
  • Requirements for screening
  • Interruptions from other clinical staff and other patients needing assistance

These contexts can put barriers in the way of clinicians having meaningful conversations with our patients around sexual health

  • Learning to address these hurdles and incorporate language and behaviors in your practice will become easier with practice
  • Implementation will, over the long term, will become seamless and improve the efficiency with which you take a sexual history

Routine review of sexual history can lead to improved patient outcomes

Words Matter: Avoiding Judgmental and Stigmatizing Language

Introductions

A provider’s approach to taking a comprehensive sexual history begins as soon as you introduce yourself to your patient

  • Consider how we greet patients and the ways in which our perceptions of their physical appearance and gender expression leads to the insertion of the titles “Mr.” or “Mrs./Ms.” before their last name.
  • Most of the time we guess correctly, but at times we may guess incorrectly and create a stigmatizing atmosphere for our patients before the full encounter even starts
  • As a result, patients may shut down and not give a fully open and honest history; some may even question if they want to follow up with us altogether

We suggest an introduction like this: “Hi, my name is Dr./NP/PA _________________. My pronouns are she/her. What would you prefer to be called and what are your pronouns?”

  • Using more open-ended language lets your patients know you are not assuming anything when it comes to their sexual and gender identities
  • Additionally, it lets them know you respect them and will address them how they would like to be addressed, not based on your assumptions

When in doubt, ask patients how they prefer to be addressed | Never make assumptions.

Language

Language is key in sexual history-taking, and questions should be framed in open-ended and affirming language that allows patients to tell their own narrative:

  • “I’m going to ask some personal questions about your sexual history now”
  • “I ask these questions to all my patients to help get a sense of their sexual health needs”
  • “What are the genders of your sexual partners”
  • “What behaviors do you enjoy when having sex”
  • “What forms of STI and HIV prevention do you use with your partners”
  • “Do you have any specific sexual health concerns you want to talk about?”

Leading with open-ended questions avoids assuming certain sexual and gender identities (or the genders of their sexual partners):

  • It allows patients to understand you are receptive to any response
  • It creates a space where they will not be judged if they acknowledge having multiple sexual partners and regardless of the consistency of their HIV/STI prevention choices
  • It allows communication to remain honest
  • It facilitates identification of necessary testing, vaccination needs, and how to move forward with a sexual health and wellness plan that works for them

Standardized Approaches to Sexual History-Taking 

There are many good resources to standardize the approach to sexual history-taking

The 5 P’s (CDC)

The most popular standardized approach to sexual history-taking comes from the CDC and is entitled “The 5 Ps” – which stand for:

  1. Partners
  2. Practices, including previous or current sex work
  3. Protection from STIs
  4. Past history of STIs
  5. Prevention of Pregnancy

These are commonly accepted categorization of the broad topics clinicians should cover during the encounter

  • They are guidelines more than hard and fast rules, ensuring thorough content in a way that feels natural to the provider
  • Flexibility is key to improve comfort and competence, including order of questions and wording

Essential Questions – Physicians for Reproductive Health

Physicians for Reproductive Health (PRH) suggests a template for sexual history-taking, particularly adolescents and emerging adults. They emphasize how to best set the atmosphere to ask sensitive sexual health questions, highlighting effective communication techniques that will help patients feel comfortable. These include:

  • Minimize note-taking, particularly during sensitive questioning
  • Talk in terms the adolescent will understand
  • Ask developmentally appropriate questions
  • Ask open-ended questions
  • Practice listening skills
  • Avoid the surrogate parent and adolescent roles
  • It’s a conversation…not an interrogation!
  • What purpose does the information serve?
  • Healthy respect and regard for privileged information

Their recommended sexual history questions cover: 

  • Gender identity : “What names and pronouns do you use for yourself?”
  • Sexual orientation “What genders are you interested in romantically?” and “Are you comfortable with your feelings?”
  • Sexual coercion, abuse, and prior or current sex work “Who makes the decisions about when to have sex and what contraception to use?” and “have you exchanged sex for goods or services?” or “have you engaged in sex work in the past or currently?”
  • Sexual activity
  • Number of partners
  • Frequency of intercourse
  • Type of sex practices
  • STI history and risk assessment “Have you ever been diagnosed with an infection?”
  • Pregnancy history and risk assessment “Have you ever been pregnant or gotten anyone pregnant?” and “What are you doing to prevent pregnancy right now?”
  • Contraceptive behaviors “What are your experiences with contraception to prevent pregnancy?”
  • Substance use

Approaching the sexual history with respect, no assumptions, and a collaborative spirit will go a long way in fostering the trust needed for honest communication about sexual health and wellness

Note: It may be helpful to explain or collaborate with the patient on how the information they provide on their sexual health will be documented in the medical record to build trust

The Wrap-Up

 The above patient will benefit from an open-ended sexual history

She is at a transitional time of her life where she is entering a new phase and would benefit from an affirming and empowering approach to her sexual health

  • Start with a discussion of her current sexual and gender identities
  • Explore what her sexual and romantic needs and desires are at this point
  • Inquire regarding her concerns and worries about returning to dating and sexual activity  after recently ending years of marriage
  • Discuss her preferred approaches to contraception
  • Evaluate her thoughts and preferred options for HIV and STI prevention (including PrEP) moving forward

KEY POINTS:

  • STI and HIV prevention discussions begin with a sexual health conversation
  • Patient-centered and tailored approaches should meet patients where they are
  • Utilize affirming language over a judgmental and discriminatory tone
  • Incorporate models of sexual history-taking that work best for your patients

Learn More – Primary Sources:

Centers for Diseases Control and Prevention

American College of Obstetricians and Gynecologists

Physicians for Reproductive Health

Human Rights Campaign Glossary of Terms

American Academy of Family Physicians

National LGBT Health Education Center

New York City Department of Health

Glossary of Sexual History Terms and Language

When taking a sexual history, it is important to lead without assuming that everyone is cis-gendered and heterosexual. Approaching the questions and how to phrase them is the art of medicine, beginning with familiarizing oneself with key sexual orientation and gender identity (SOGI) terms that will help facilitate an open atmosphere in which patients feel comfortable discussing their sexual lives

Below is an abbreviated list of terms. A more expansive glossary is found on the HRC website. While it is possible that the majority of patients you encounter in clinical practice may identify as cis-gendered and heterosexual, it is paramount to create clinical spaces that are affirming and inclusive of all patients along the sexual and gender identity continuum. You may not need to use these terms with every patient and during your clinical sessions, but it is important to at least familiarize yourself with the terminology. This way we can service anyone’s sexual health needs and priorities, regardless of how they identify

According to the Human Rights Campaign (HRC), these are some basic terms and definitions around sexual identity and gender identity (SOGI) with which clinicians can familiarize themselves:

Sexual orientation | An inherent or immutable enduring emotional, romantic, or sexual attraction to other people

Lesbian | A woman who is emotionally, romantically, or sexually attracted to other women

Gay | A person who is emotionally, romantically, or sexually attracted to members of the same gender

Bisexual | A person emotionally, romantically, or sexually attracted to more than one sex, gender, or gender identity though not necessarily simultaneously, in the same way or to the same degree

LGBTQ | An acronym for “lesbian, gay, bisexual, transgender and queer”

Queer | A term people often use to express fluid identities and orientations. Often used interchangeably with “LGBTQ”

Gender identity | One’s innermost concept of self as male, female, a blend of both or neither—how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different from their sex assigned at birth

Cisgender | A term used to describe a person whose gender identity aligns with those typically associated with the sex assigned to them at birth

Transgender | An umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth. Being transgender does not imply any specific sexual orientation. Therefore, transgender people may identify as straight, gay, lesbian, bisexual, etc.

Gender dysphoria | Clinically significant distress caused when a person’s assigned birth gender is not the same as the one with which they identify. According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), the term—which replaces Gender Identity Disorder—”is intended to better characterize the experiences of affected children, adolescents, and adults”

Gender expression | External appearance of one’s gender identity, usually expressed through behavior, clothing, haircut or voice, and which may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine

Genderqueer | Genderqueer people typically reject notions of static categories of gender and embrace a fluidity of gender identity and often, though not always, sexual orientation. People who identify as “genderqueer” may see themselves as being both male and female, neither male nor female, or as falling completely outside these categories

Gender transition | The process by which some people strive to more closely align their internal knowledge of gender with its outward appearance. Some people socially transition, whereby they might begin dressing, using names and pronouns, and/or be socially recognized as another gender. Others undergo physical transitions in which they modify their bodies through medical interventions

Non-binary | An adjective describing a person who does not identify exclusively as a man or a woman. Non-binary people may identify as being both a man and a woman, somewhere in between, or as falling completely outside these categories. While many also identify as transgender, not all non-binary people do

Sex assigned at birth | The sex (male or female) given to a child at birth, most often based on the child’s external anatomy. This is also referred to as “assigned sex at birth”

Commercial Support

This educational activity is supported by an independent educational grant from Gilead Sciences

Faculty Disclosures

David Malebranche, MD, MPH serves on the PrEP speakers bureau for Gilead Sciences, Inc

Ariel Watriss, MSN, NP-C has no relevant financial relationships to disclose