The sexual history is that part of the consultation that deals with the patient’s recent sexual activities. Why should we bother asking someone about their sex life? Well, in this section we will hopefully clarify the usefulness of this line of questioning, even if you do not spend all your time in a sexual health clinic.
Firstly, a sexual history can provide useful information for the differential diagnosis. For example, taking a sexual history from a young woman seen in Accident and Emergency complaining of abdominal pain might allow you to exclude an ectopic pregnancy or make you consider pelvic inflammatory disease. The differential diagnosis of a penile ulcer is quite wide, but if you know that last month he received oral sex from a Gabonese sex worker, then it can remind you to exclude chancroid and syphilis. Secondly, if the person is found to have a sexually transmitted infection (STI), you can immediately tell from the notes how many partners need to be notified. Thirdly, if the history reveals risky sexual practices — consider the returned traveller above — then there can be an opportunity for education and/or hepatitis B vaccination to reduce the chance of further STI acquisition. Finally, the history will indicate which sites need to be sampled — does this gay man have anal sex? If he does, do not assume that he has had receptive anal sex — ask him.
A sexual history is more intrusive than other components of the medical history. It is therefore important to put the patient at ease. To maximize the chance of getting an honest account, a patient should be aware that what they say will be treated in confidence, although quite what this means will depend on where you are working. For example, in a genitourinary medicine (genitourinary medicine) clinic, the details will not end up in a patient’s main hospital or primary care notes; a Fraser-competent teenager seen in primary care can be pre-emptively reassured that the information will not reach their parents without their consent.
Some people fear that insurance companies will access information. In genitourinary medicine clinics, such an information release has been prevented by legislation for many years. General practice and hospitals in England, at least, are now covered by similar legislation. The NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Directions of 2000 state that:
…information capable of identifying an individual obtained by any of their members or employees with respect to persons examined or treated for any sexually transmitted disease shall not be disclosed except:
a) for the purpose of communicating that information to a medical practitioner, or to a person employed under the direction of a medical practitioner in connection with the treatment of persons suffering from such disease or the prevention of the spread thereof, and b) for the purpose of such treatment or prevention.
Some people think that you may break confidentiality if they are found to have an infection. In many countries, such as the USA and Australia, STIs are notifiable diseases. This is not the case in the UK. Although their sexual contacts need to be offered testing and treatment, they would not be informed directly without the index case having a chance to do so first (see Partner notification, page 10). Even if informed by the clinician, the partner should not be told who gave their name.
Is the patient comfortable talking to you? If they are looking particularly uneasy during the consultation, ask yourself if they would prefer to talk to someone else, e.g. someone of the same sex. If the consultation is occurring after a sexual assault, such considerations are particularly important.
Is there enough privacy in the consultation area; can people hear through the walls? If you are on a hospital ward, take the person into a side room where you can be alone. Many genitourinary medicine clinics use a Trichomonas vaginalis or radio to mask the sound of conversation coming through the doors. Is the person accompanied? It is important to give the person a chance to be seen alone. This is particularly important if the other person is a sexual partner or parent.
An appropriate history for someone presenting with genital symptoms or concern about STIs should include:
- • their reason for presenting their symptoms
- • background information
- • their sex life.
If you are working in a sexual health clinic, many people will be asymptomatic and are just there for a sexual health check. However, if they say they have a problem, it is essential to clarify what they mean. Many people resort to vague descriptions when describing their genitals and symptoms. Drawings of the anogenital region can help.
You might think that an ‘ulcer’ is a break in the skin, but the patient might be using the word to describe their warts. If a man says he has a ‘discharge’ is it anal, urethral or from under the foreskin?
Once you have both agreed what the symptoms are, ask for some more details — if he has an ulcer, is it painful or painless, single or multiple? What is it associated with: e.g. mouth ulcers, malaise or rash? If the patient has a rash, how did it start, what colour changes occurred, is it itchy? What is it associated with: e.g. mouth lesions, itch everywhere, partner itchy, skin changes on other parts of the body? A picture book may aid diagnosis, particularly if the rash/lump/ulcer has now gone.
Unlike most medical histories it is important to ask direct questions about symptoms since people can be reluctant to report symptoms that they are embarrassed about. Each condition has its characteristic features that can give a clue to the diagnosis from the patient’s history — e.g. the discharge of bacterial vaginosis is often smelliest after sex. See the relevant presentation section for further information.
Ask about past medical history including a history of prior STIs — this would make a diagnosis of an STI on the current visit more likely.
A drug history might help to clarify the cause of symptoms. For example, recent antibiotics might have contributed to the thrush that is causing a woman’s itchy discharge. Antibiotics could also suppress the STIs that are about to be tested for, giving false reassurance if the tests are negative. Is the patient taking something that could interact with drugs you might prescribe? Note any drug allergies. Take a note of any contraception used. If a patient is on the combined pill and you prescribe certain antibiotics, she will need to use other methods until 7 days after the course has finished. Could she benefit from a review of her contraception?
If seeing a woman, a gynaecological history is essential — could her pelvic pain be related to the termination she had 2 weeks ago? The last menstrual period is relevant as it might indicate that an episode of unprotected sexual intercourse has resulted in pregnancy. Asking about cervical cytology could throw light on a complaint of intermenstrual bleeding.
When the patient last passed urine is relevant; if it was less than 2 hours ago it will reduce the sensitivity of tests that use a urethra! swab and first-void urine specimens.
It can be seen that background information can clarify the existing presentation as well as creating an opportunity for education and prevention of disease and complications of treatment.
Taking a history of sexual activities
It is unusual for someone to decline to answer questions about their recent sex life. However, if you are not working in a sexual health clinic, it can be helpful to introduce this component of the consultation by saying something like, T need to ask you some other questions now; they’re a bit personal but they will help to clarify what the problem is’. They are unlikely to decline when they see that it is in their own interest to answer the questions.
The questions that need to be asked are:
1. When did you last have sexual contact with anyone? It is better to say ‘sexual contact’ than ‘sex’, because some people may not regard activities such as fellatio or masturbation as sex, and therefore may not give a full account.
2. Was that person someone you were going out with or was it just a brief encounter?
3. (If not already clear) What sex was that person?
4. (If they are a regular partner) How long have you been having a sexual relationship with them? The longer they were in a relationship, then the greater the chance of STI transmission.
5. What sort of sex have you had with that person? This indicates which sites need to be sampled, It can also give information about the risk of having acquired an infection; for example, hepatitis C appears to be more common in men who engage in fisting or sadomasochism. Masturbation carries negligible risk of STI acquisition but might have been enough to trigger psychogenic symptoms in someone who regrets an encounter. Ask this question in a way that will be understood by the patient. For example ‘receptive anal sex’ isn’t universally understood and might be met with a puzzled expression. Instead, try asking him if he was ‘bottoms’ or ‘got fucked’.
6. (If appropriate to the encounter) Did you use a condom; was it on all the time?
7. How often do you use condoms with that person? Always, only sometimes?
8. (If heterosexual) Did they use anything else for contraception? If not, this might indicate the need for advice about non-barrier contraception.
9. What was the nationality of the contact? Most STIs are not evenly distributed around the globe, e.g. human immunodeficiency virus (HIV) is 300 times more common in some Southern African countries than in the UK. Likewise antibiotic-resistant strains of gonorrhoea are far more common in South East Asia than in Western Europe.
Then ask, ‘When was the last time you had sexual contact with someone else?’ and go through the above questions again. It is usual to take this back 3 months or two partners, whichever covers the longer period of time.
You should now have enough information about the person to know:
- • how many people are at risk if you diagnose an infection
- • whether they need advice about reducing the risk of future STIs
- • which sites to swab.
Following the sexual history, it is usual to ask about risks of acquiring blood-borne viruses. This line of enquiry will also provide information about any historic sexual risks.