Let's Talk About Sex: Tips for How to Take a Sexual History

Rosalyn E. Plotzker, MD, MPH

Disclosures

January 11, 2018

The recent Centers for Disease Control and Prevention (CDC) report on sexually transmitted diseases (STDs) for 2016 showed increased incidence for the third consecutive year. National totals included 1.59 million cases of chlamydia (4.7% increase), 468,514 cases of gonorrhea (18.5% increase), and 27,814 cases of primary and secondary syphilis (17.6% increase), with an alarming 27.6% rate increase in congenital syphilis cases. The dramatic rise of these diseases is a cue for clinicians to better understand patient sexual practices and preferences. As trainees, now is the time to hone sexual history–taking skills.

Sexual health extends well beyond infections. The World Health Organization defines sexual health as "a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health 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."

Beyond preventing and treating infection, sexual histories are crucial for patients with concerns related to fertility and contraception, gender expression, sexual violence, medication side effects, postmenopausal health, or even erectile dysfunction, which may hint at cardiovascular or endocrine disease. These are important discussions but they can be difficult to initiate.

How do you get a thorough sexual history from someone who is potentially very different from you or who has their own ideas of what is actually relevant to their health? What assumptions do doctors and patients bring into the exam room? These questions surface during residency but can continue or resurface well into clinical careers.

The basic goal of a sexual history is the same as for any other history: to understand a patient's health and clarify a differential. Its use varies from specialty to specialty. The use of a sexual history to a gynecologist or urologist is obvious. In primary care, taking a sexual history can spin into counseling and screening for STDs or discussions about pre-exposure prophylaxis (PrEP) eligibility. Meanwhile, an emergency medicine resident needs to take a sexual history in the setting of patient with pain suspicious for pelvic inflammatory disease or an ectopic pregnancy, for example. A dermatology resident may ask about sex if secondary syphilis is included in the differential diagnoses for a suspicious rash.

Regardless of specialty, virtually every physician will need to discuss sex with a patient at some point. The more you practice during training and residency, the stronger your skills will be when you need to use them. The following are best practices and suggestions.

Basic Principles

Everyone develops their own style for talking about sex with patients. That said, a few basic principles should be remembered. Never assume anything. Always remain nonpunitive, nonjudgmental, and noncoercive. If, at any point, someone tells you that they do not want to discuss something, respect their boundaries. Likewise, note your own areas of discomfort and monitor your reactions.

The period of time covered within a patient’s "history" is not definitive, but a general rule of thumb is to ask about the past 12 months. Some providers ask patients about the past 3 or 6 months, or simply about what's happened since the patient was last in the office.

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