Nobody said being a physician would be an easy task, and probably the most difficult of all interview skills is eliciting a sexual history. Chances are neither you nor your patient is excited about the process, but it’s a vital measure of health.
Consider that the US rates of sexually transmitted diseases and infections are increasing instead of decreasing. Rates of syphilis, for instance, are breaking historic records nationally. The rate among all Americans increased 73% from 2013 to 2017, and jumped 156% in women during the same period.
Despite such health dangers, physicians rarely ask about sex. In contrast, nearly all physicians ask about smoking history, despite that only about 15% of US adults are current smokers.
Improving your sexual history-taking skills will benefit both your practice of medicine and the health of your patients.
Eliciting a patient’s sexual history is a sensitive manner that should be taken seriously. To begin with, appropriate bedside manner is absolutely necessary. You should also enter the conversation armed with tact and cultural understanding.
Before the interview, it’s important to take a few minutes to get prepared. Keep in mind the following during this time of reflection:
- Remain nonjudgmental.
- Assure confidentiality.
- Be specific and direct with questions, such as:
- “Do you have sex with men, women, or both?”
- “Do you identify as gay, straight, or bisexual?”
- “How many sexual partners have you had in the past 12 months?”
- Don’t use jargon (eg, use “swelling” instead of “edema”).
- Ask about sexually transmitted infections and diseases; if the patient looks confused, ask about symptoms related to each.
- Ask about preventive and sexual risk behaviors (eg, type of birth control being used).
- Avoid assumptions based on a patient’s characteristics.
- Discuss situations that may put the patient at increased risk, such as substance misuse, to develop a blueprint for later action.
For a brief sexual history, begin the patient interview with a request for the chief complaint; a direct approach will work best. You can begin by asking, “What change in sexual function is resulting in distress?”
Next, it’s important to trace a history of the present illness. Specific questions to ask include:
- Does the issue occur during masturbation or while with a partner?
- Is the issue situational or generalized?
- What influence does the issue have on your or your partner’s quality of life?
- What strategies or medications have you used to address the problem?
Brief symptom checklists are useful while taking sexual histories. In women, for example, items in a brief symptoms checklist could include assessment of interest in sex, genital sensation, lubrication, ability to achieve orgasm, and the presence of pain during sex.
Keep in mind that various health conditions can affect sexual health, including:
- Cardiovascular disease
- Neurological conditions
- Endocrine deficiencies
- Psychiatric disorders
- Benign prostatic hypertrophy (men) or gynecological disease (women)
Consider whether the patient would benefit from specialized referral, including consultation with a marriage counselor or sex therapist.
Although rates of HIV are decreasing, these reductions are uneven, and some communities are still hard hit. Moreover, rates of chlamydia, gonorrhea, and syphilis are on the rise—all of which can increase a patient’s risk for HIV infection.
Carefully consider whether the patient will benefit from HIV counseling. For instance, black men who identify as gay have a 50% lifetime risk of becoming HIV-positive.
When discussing HIV, it’s important to find out whether the patient has any concerns about possible infection. If so, you can then present pre-exposure prophylaxis, or PrEP, as an option to prevent infection.
Know your patient
Your ability to comprehensively elicit a sexual history depends on your relationship with the patient. Every new patient should have an initial sexual history taken as part of the social history.
This initial history includes age of first sexual experience, biological sex of partners, types of sexual practices, frequency of masturbation, history of sexually transmitted infections, safe sex practices, and method of birth control used.
Once you establish a rapport with your patient, you can better advise them using a tailored approach. Remember that not all patients are the same.
Often, changes in sexual activity follow major life changes. Major life changes include dating, divorce, initiating a new request for birth control, moving, traveling, or first year in college. If you know your patient well, you can learn more about these issues during continuity of care.
Finally, it’s a good idea to make pamphlets and patient-based literature available to your patients to complement your efforts at patient education. These pamphlets are available from the CDC.