Professional Documents
Culture Documents
Sexual History Taking
Sexual History Taking
Sexual History Taking
Introduction
Introduce yourself – name / role
Explanation/consent:
“I’ve been asked to take a sexual history from you, this is going to involve me asking some personal
questions which you may find uncomfortable. Everything you tell me is confidential within the
boundaries of the team looking after your care. If you would like to stop at any time, please let me
know.”
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
Allow the patient time to answer, trying not to interrupt or direct the conversation.
“Ok, so tell me more about that” “Can you explain what that pain was like?”
“Have you noticed any discharge? Does it smell? What does it look like?”
Dysuria / frequency
“Do you have any pain when passing urine? Do you feel you are going more often?”
Vulval itching/soreness
“Do you have any itching/soreness down below?”
“Have you noticed any blisters, spots or ulcers around your vagina or anus?”
“Have you had any pain in your tummy?” “Where in the tummy is the pain?”
“Do you ever experience any pain around the time of sex?”
“Does the pain feel to be within the vagina, or deep in your stomach?”
“Do you have any pain in your joints?” “Have you had any pain in your eyes?”
Menstrual history
Last menstrual period (LMP) – “When was your last period?”
Length of cycle – “How long is your cycle? / How long do you bleed for?”
Post-coital bleeding – “Do you experience any bleeding after sexual intercourse?” (new vs
longstanding)
Obstetric history
Contraception – type of contraception, length of use, any issues, any previous contraception
Current pregnancy? – “Are you or do you think you may be pregnant at the moment?”
Swellings “Have you noticed any swellings or change in size of your testicles?”
“Have you noticed any lumps, bumps or ulcers around your penis/testicles/anus?”
“Do you have any pain or burning in your genitals or your stomach when you pass urine?”
“Do you feel you are passing urine more often?” “Is there any blood in your urine?”
“Next, I’m going to move on to discuss your sexual history. Some of these questions are sensitive,
and can make people feel embarrassed. It’s important for me to find out this information though, so
we can assess the risk of you being in contact with a sexually transmitted infection, and any others
involved.”
Timing of last sexual contact “When did you last have a sexual encounter?”
Consensual?
For oral/ anal sex, clarify if the patient gave or received it (or both)
“What was involved in this encounter?” “Was there more than one other person involved?”
Clarify if contraception was used for all sexual encounters, or only a subset.
Ask if there was any problems with contraception at any point – e.g. condom splitting
“Was there any point at which contraception was not used during the sex?”
“Have you had any other partners within the last 3 months?” – if so, repeat the above for each
Medical/surgical problems “Is there anything you see the doctor regularly for?”
“Have you been in hospital for anything in the past?”
Drug history
Current medications Recent antibiotics
ALLERGIES
Social history
Smoking – How many cigarettes do they smoke a day? / How many years have they smoked for?
Alcohol – How many units a week? – Be specific about type / volume / strength of alcohol
Recreational drug use – IV drug use is a risk factor for Hepatitis / HIV
Also consider if it is appropriate to ask the age of partner(s), and be aware of safeguarding issues,
especially surrounding the social factors related to sexual encounters.
“Have you ever had sex with a bisexual man/engaged in male homosexual activity?”
“Have you ever had sex with someone abroad, or who was born in a different country?”
“Are you aware of any of your previous partners having ever injected drugs?”
“Have you ever paid someone for sex, or been paid for sex?”
Thank patient