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

Rosalyn E. Plotzker, MD, MPH

Disclosures

January 11, 2018

Wording

In terms of language, ask all questions directly. Euphemisms get you nowhere.

It is also essential to use plain terminology. For example, a gay male patient might understand "topping" or "bottoming" more readily than "insertive" or "receptive" anal sex. If you don't recognize a term, don't be afraid to ask the patient about it.

Finally, when talking with transgender or nonbinary patients, in addition to asking about pronoun preference, ask about preferred anatomy terms (eg, does a patient who is a transman prefer "front hole" or "vagina"?).

Broaching the Subject

From many patients' points of view, understanding why they need to discuss their sex lives at all is helpful. In primary care, assure patients that all adults are asked these questions, regardless of age or marital status; emphasize confidentiality. In specialty settings, where differentials are more likely to guide questioning, simply explaining that knowing about sexual practices helps identify possible causes of their problem and how to proceed (eg, which tests to order) may be beneficial.

Components of a Sexual History

A common acronym is the "Five P's". This refers to partners, practices, protection, past history of STDs, and prevention of pregnancy.

  • Partners: This is an ideal place to start, as it guides the remaining "P" questions. Sexual partner history usually includes discussion of oral, anal, and vaginal sex, so be sure to mention those. Begin with gender: Man? Woman? Transman? Transwoman? Nonbinary? One strategy is to ask about how many partners within each group, rather than simply asking "yes" or "no." For example, "How many men have you had sex with in the past 6 months? How many women?" Ask how many partners are new, which could suggest disease risk. Finally, ask about partner-specific risk factors such as injection drug use, partners' disease statuses, and so on.

  • Practices: Being systematic helps. Ask about vaginal sex, anal insertive sex (topping), anal receptive sex (bottoming), giving oral sex, and receiving oral sex. For patients with vaginal or rectal complaints, ask about sex toys and douching.

  • Protection: "How do you protect yourself from STDs?" is a good, open-ended way to start. Alternatively, you could be specific about consistency of condom use, regular STD testing, and communication with partners about STDs. This is also an opportunity to discuss STD chemoprophylaxis, such as human papilloma virus (HPV) vaccines, PrEP, and postexposure prophylaxis (PEP).

  • Past history of STDs: Ask about specific infections (eg, herpes, syphilis, chlamydia, gonorrhea, HPV, genital warts, proctitis, epididymitis), some of which patients may not immediately think of as STDs. In addition to asking about the number of times they have had these infections, ask about treatment and whether their partner was treated. This may also be a good chance to emphasize the importance of prevention.

  • Prevention of pregnancy (if patient is of reproductive age): You may ask, "Are you trying to get pregnant right now?" If no, then identify the current contraception method and family planning goals, if appropriate.

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