Guide to Taking a Sexual History

Introduction

A sexual history should be taken as part of routine health care, as well as when there are symptoms or physical exam findings suggestive of STIs. In short, a sexual history allows you to provide high-quality patient care by appropriately assessing and screening individuals for a broad range of sexual health concerns.

This guide is meant to provide you with a sample of the discussion points and questions that may be asked. It is not meant to be a standard for diagnosis or a complete reference for sexual history taking. An adequate sexual history should be tailored to each person based on their preferences and the clinical situation. Providers may need to modify questions to accommodate a person's gender identity, race/ethnicity, culture, or other important considerations.

Clinical Environment

Creating a welcoming clinical environment for all patients should begin at registration. Establishing your patient's name and pronouns, as well as their sexual orientation and gender identity, are important in medical care. Gender identity is independent of sexual orientation and best determined by a two-step method incorporated into a clinic's initial assessment that asks sex assigned at birth (female, male, or decline to answer) and current gender identity (female, male, transgender female, transgender male, gender diverse, additional gender category, or decline to answer).

In addition, some patients may not be comfortable talking about their sexual history, sex partners, or sexual practices. Some patients may have experienced abuse or trauma in their lives or while in a medical setting. Training in a trauma-informed care approach can help all clinicians apply patient-centered, sensitive care to all interactions. Some patients may be experiencing intimate partner violence and seeking care for medical health concerns could be their only opportunity to access safe resources. Try to put patients at ease and be prepared to link patients to needed resources. Let them know that taking a sexual history is an important part of a regular medical care. In some cases, simply offering all testing options may be the best approach.

Dialogue with patient

• May I ask you a few questions about your sexual health and sexual practices? I understand that these questions are personal, but they are important for your overall health.
• At this point in the visit I generally ask some questions regarding your sexual life. Will that be ok?
• I ask these questions to all my patients, regardless of age, gender, or marital status. These questions are as important as the questions about other areas of your physical and mental health. Like the rest of our visits, this information is kept in strict confidence unless you or someone else is being hurt or is in danger. Do you have any questions before we get started?
• Do you have any questions or concerns about your sexual health?

The Five “P”s

To further guide your dialogue with your patient, the 5 "Ps" may be a useful way to help you remember the major aspects of a sexual history.

1. Partners
2. Practices
3. Protection from STIs
4. Past History of STIs
5. Pregnancy Intention

These are the areas that you should openly discuss with your patients. You probably will need to ask additional questions that are appropriate to each patient's special situation or circumstances, but the goal of the 5Ps is to improve patient health, not simply to solicit full disclosure of sexual practices, especially if patients are not comfortable.

PARTNERS

To assess the risk of getting an STI, it is important to determine the number and gender of your patient's sex partners. Remember: Never make assumptions about the patient's sexual orientation or the gender identity of the patient or partners. Even if only one sex partner is noted over the last 12 months, be certain to inquire if that partner is a new sex partner. Ask about the partner's risk factors, such as other concurrent partners, past sex partners or drug use.

Dialogue with patient

• Are you currently having sex of any kind – so, oral, vaginal, or anal – with anyone? (Are you having sex?)
• If no, have you ever had sex of any kind with another person?
• In recent months, how many sex partners have you had?
• What is/are the gender(s) of your sex partner(s)?
• Do you or your partner(s) currently have other sex partners?

PRACTICES

Asking about sex practices will guide the assessment of patient risk, risk-reduction strategies, the determination of necessary testing, and the identification of anatomical sites from which to collect specimens for STI testing.

Dialogue with patient

• I need to ask some more specific questions about the kinds of sex you have had over the last 12 months to better understand if you are at risk for STIs. We have different tests that are used for the different body parts people use to have sex. Would that be OK?
• What kind of sexual contact do you have, or have you had? What parts of your body are involved when you have sex?
  • Do you have genital sex (penis in the vagina)?
  • Anal sex (penis in the anus)?
  • Oral sex (mouth on penis, vagina, or anus)?
  • Are you a top and/or bottom?
• Do you meet your partners online or through apps?
• Have you or any of your partners used drugs?
• Have you exchanged sex for your needs (money, housing, drugs, etc.)?

To learn more about the patient's sexual practices, ask open-ended questions that are focused on the information you need to know based on what you have already learned about the patient. Based on the answers, you may discern which direction to take the dialogue.

PROTECTION FROM STIs

Clinicians should determine the appropriate level of risk-reduction counseling for each patient. For example, if a patient is in a mutually monogamous relationship, risk-reduction counseling may not be needed unless the patient or their partner is engaging in activities that will put them at risk.

You may need to explore the subjects of abstinence, or not having sex, number of sex partners, condom use, the patient's perception of their own risk and their partner's risk, and STI testing. It is important to not assume risk or lack of risk for any patient.

Dialogue with patient

• Do you and your partner(s) discuss STI prevention?
• If you use prevention tools, what methods do you use? (For example, external or internal condoms – also known as male or female condoms – dental dams, etc.)
• How often do you use this/these method(s)? More prompting could include specifics about:
  • Frequencies: sometimes, almost all the time, all the time.
  • Times they do not use a method.
• If "sometimes," in which situations, or with whom, do you use each method?
• Have you received HPV, hepatitis A, and/or hepatitis B shots?
• Are you aware of PrEP, a medicine that can prevent HIV? Have you ever used it or considered using it?

PAST HISTORY OF STIs

A history of prior STIs may place your patient at greater risk now.

Dialogue with patient

• Have you ever been tested for STIs and HIV? Would you like to be tested?
• Have you been diagnosed with an STI in the past? When? Did you get treatment?
• Have you had any symptoms that keep coming back?
• Has your current partner or any former partners ever been diagnosed or treated for an STI? Were you tested for the same STI(s)? Do you know your partner(s) HIV status?

PREGNANCY INTENTION

Based on information from the prior section, you may determine that the patient or the patient's partner(s) could become pregnant. Questions should be focused on determining pregnancy intention and what information they need.

Dialogue with patient

• Do you think you would like to have (more) children at some point?
• When do you think that might be?
• How important is it to you to prevent pregnancy (until then)?
• Are you or your partner using contraception or practicing any form of birth control? Would you like to talk about ways to prevent pregnancy? Do you need any information on birth control?

Finishing the session

By the end of the interview session, the patient may have come up with information or questions that they were not ready to discuss earlier.

Dialogue with patient

• What other things about your sexual health and sexual practices should we discuss to help ensure your good health?
• What other concerns or questions regarding your sexual health or sexual practices would you like to discuss?

Ask your patient about a history of trauma, sexual abuse, or violence, as these are common, and patients may benefit from additional care (e.g., Has anyone ever made you do something sexual that you did not want to?)

Also consider asking about sexual functioning, including pleasure and performance, and referring for care, as indicated.

At this point, thank the patient for being open and honest. Point out and encourage any protective practices.

For patients at risk for STIs, be certain to encourage testing and give positive feedback about prevention methods that the patient is willing or able to use. Explain that STI/HIV prevention methods (or strategies) can include:

• Not having sex.
• Mutual monogamy, or both partners having sex with only one another.
• Using PrEP.
• Using condoms the right way every time a person has sex.

These approaches can avoid or effectively reduce the likelihood of getting an STI/HIV through abstinence or mutual monogamy, proper condom use, and STI/HIV testing.

Focusing on sexual health goal setting for healthy and safe sexual experiences can be paired with risk-reduction strategies to bridge the transition to a counseling referral if one is recommended.

Authors and Acknowledgements

References

Hatcher, R.A., Nelson, A.L., Trussell, J., Cwiak C., Cason, P., Policar, M. S., Edelman, A., Aiken, A. R. A. , Marrazzo, J., Kowal, D. (2018). Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc.

Geist C, Aiken AR, Sanders JN, Everett BG, Myers K, Cason P, Simmons RG, Turok DK. (2019). Beyond intent: exploring the association of contraceptive choice with questions about Pregnancy Attitudes, Timing and How important is pregnancy prevention (PATH) questions. Contraception. 99(1):22-26.

The Nuts and Bolts of SOGI Data Implementation: A Troubleshooting Toolkit

GENIUSS Group (Gender identity in U.S. surveillance) (2013) Gender-related measures overview Los Angeles: The Williams Institute. Available: The Williams Institute: Gender-Related Measures Overview.