Sexual health is a multi-faceted, broad concept which is not just narrowly defined by issues such as sexually transmitted infections (STIs), pregnancy and contraception but is a ‘state of physical, emotional and social well-being in relation to sexuality’ (World Health Organization [WHO], 2006). Physical sexual health does not just imply the absence of disease but being enabled to make positive health choices and being able to access services when needed.
Positive sexual health outcomes are seen as important to individuals and they have also been recognised by the government as a major public health issue.
There have been some achievements in public heath targets set by government, namely a decline in teenage pregnancy and more high risk groups being offered and accepting HIV tests (Department of Health, 2013). But there are still major challenges: there were approximately 468 342 sexually transmitted infection diagnoses made in England in 2019 (Public Health England, 2020); up to 50% of pregnancies were unplanned; and almost half of adults newly diagnosed with HIV were diagnosed after the point where they should have started treatment (Department of Health, 2013).
There is evidence that health professionals find sexual history taking to be one of the more challenging aspects of a consultation. There are a number of different reasons for this: feeling not equipped to ask questions of such a sensitive nature; fear of opening a ‘can of worms’ which cannot be dealt with; and the general social embarrassment and difficulties experienced talking about sex in general (Bates, 2011).
This article will attempt to give health professionals some tips and guides to help make a sexual history taking session as comfortable as possible for both health professional and patient.
Environment
STIs still carry a degree of stigma in society and to enable a patient to feel free to disclose information to the health professional they need to be confident that their privacy will be respected. It is useful to have the practice confidentiality statement posted in the waiting room for all patients to see before their consultation (British Association for Sexual Health and HIV [BASHH], 2019; Faculty of Sexual and Reproductive Healthcare, 2020).
Confidentiality is one of the most important principles in sexual health and is enshrined in law through the NHS venereal disease regulations of 1974. These regulations state:
‘Information about anybody diagnosed with a sexually transmitted infection should 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 and prevention.”
Taking care to ensure that the patient cannot be overheard and the consultation will not be interrupted will make sure the patient feels confident to share personal and sensitive information. With the increase in remote consultations during the recent COVID-19 pandemic, issues such as confidentiality need to be reconsidered. Ensuring the identity of the patient on the end of the phone by asking for identifiers such as date of birth is essential. Also, it is just as important to maintain a confidential environment in a remote consultation by closing clinic doors and ensuring the patient is not overheard.
Communication
Introducing the topic of sexual health into a consultation can seem very challenging, but patients may be unwilling to broach the subject themselves and may be waiting for the health professional to bring it up (Bates, 2011; Dyer and das Nair, 2013). Raising the subject of sexual health and including this as part of routine questioning can make the discomfort less.
A welcoming, comfortable, confidential physical environment is likely to encourage openness and candour when discussing sensitive issues, such as sexual behaviour. (BASHH, 2019; FSRH, 2020).
The importance of the initial greeting cannot be overstated. Patients will use this initial meeting to assess whether they are safe with the health professional in front of them to share intimate information. If the health professional appears distracted, busy or impatient, this can hinder the channels of communication. It is important to maintain eye contact (if culturally acceptable) and use appropriate body language such as an open posture rather than behind a desk or using a barrier such as a computer screen. A friendly introduction and eye contact help set the scene and aid comfort and confidence (BASHH, 2019). Active listening skills should be employed, avoiding distractions such as looking at a desktop. It is helpful to start with questions of a less sensitive nature, for example general medical history, before embarking on more sensitive questions.
Health professionals can pre-empt any discomfort by asking a signposting question which pre-warns the patient of the questions that are coming and gives a rationale for their inclusion in the dialogue.
Below is an example of a signposting starter question:
‘Today I need to take a sexual history from you; this is going to involve me asking some personal questions. Everything you tell me is confidential. If, however, we felt you or someone else was in significant danger, we might have to break this confidentiality, to prevent harm. If you would prefer not to answer a particular question or you'd like to stop the consultation at any point, please let me know.’
Open-ended questions help the patient express thoughts and feelings and have a sense of these thoughts being validated. Closed questions tend to limit the range of responses (Royal College of Nursing [RCN], 2015). However, closed questions can be useful at the beginning of the consultation to elicit demographic information and establish trust. Ensure language used is clear, understandable and with which both clinician and patient are comfortable. Be aware of the patient in front of you while asking questions and be alert to any verbal or non-verbal cues that could signal distress or discomfort.
It is also imperative to remember that many ranges of relationships and sexualities exist and not to assume a heteronormative model. Heteronormativity is the belief that heterosexuality is the preferred or normal mode of sexual orientation. It assumes gender is binary and that sexual relations are the most fitting between people of the opposite sex. Using expressions such as partner and not assuming heterosexual relationships ensure an inclusive approach is maintained. It is important to clarify how the patient identifies with regard to sexuality and gender. This can be established at the beginning of the consultation as well as the preferred pronoun the patient would like to use and how they would prefer to be addressed. Understanding the difference between sex, which is assigned at birth, and gender, which is related to a person's identity, is imperative to understanding the patient. Therefore, health professionals should understand that gender identity is not necessarily fixed and can be fluid over time (RCN, 2016).
In January 2016, the House of Commons Women and Equalities Select Committee found that ‘trans people encounter significant problems in using general NHS services, due to the attitude of some clinicians and other staff who lack knowledge and understanding – and in some cases are prejudiced’ (House of Commons, 2016). As a nurse, care is provided for people from diverse backgrounds and it is important to create a safe, welcoming environment for all patients (RCN, 2016).
History components
Symptom assessment to guide examination and testing
Patients can disclose a number of different symptoms (Table 1). Once the symptom has been disclosed, the health professional needs to clarify the duration of the symptom, any home treatments that have been tried and also to be aware of any red flag symptoms that need escalating, such as post-menopausal bleeding or post-coital bleeding in women. It is useful to enquire if the patient has had these symptoms before and whether they have been diagnosed with any sexual infections in the past. To ensure a comprehensive and full history, the patient should also be asked about past or present significant medical history, medications, allergies, drug and alcohol use and, if the patient is assigned female at birth, any obstetric, gynaecological and cervical smear history.
Table 1. Symptoms that patients may present with
| Women | Men |
|---|---|
| Unusual vaginal discharge | Urethral discharge |
Vulval skin problems:
|
Genital skin problems:
|
| Lower abdominal pain/deep dyspareunia | Dysuria |
| Dysuria | Testicular discomfort or swelling |
Unusual vaginal bleeding including:
|
Peri-anal, anal symptoms |
Sexual history to identify which sites need to be sampled and the STIs to which the patient may be at risk
The sexual history of the patient's sexual contact(s) within the last 3 months needs to be recorded including the gender of partner, the relationship with the partner (casual/regular/known), duration of the relationship and whether they could be contacted. The patient should be asked about any symptoms or high-risk behaviour of the partner. All men should be asked if they have ever had sex with another man. The type of sexual contact/sites of exposure (oral, vaginal, anal, touching) needs to be explored, as well as any condom use/barrier use (and whether properly used). Finally, the time since contact needs to be established as this can help decide on testing, as infections have different ‘window periods’ before testing can give an accurate result (Table 2). Table 3 provides a summary of routine STI testing.
Table 2. Window periods
| Condition | Time window |
|---|---|
| Chlamydia and gonorrhoea | 2 weeks |
| HIV | 45 days |
| Syphilis | 3 months |
| Hepatitis A, B and C | 30–180 days |
Table 3. Routine testing
| Asymptomatic male or assigned male at birth | Chlamydia and gonorrhoea (GC) urine test | HIV and syphilis blood test |
|---|---|---|
| Asymptomatic female or assigned female at birth | Chlamydia and gonorrhoea (GC) high vaginal self swab NAAT test | HIV and syphilis blood test |
| Men who have sex with men (MSM) | Triple site chlamydia and gonorrhoea testing – rectal and throat swab and urine testing | HIV and syphilis blood test plus hepatitis A, B and C |
Contraception use and risk of pregnancy
Women should be asked about current and past contraception used and emergency contraception offered if required.
A blood-borne virus risk assessment should be carried out to guide testing
Patients who live in an area of high (2–5 per 1000 people) and extremely high HIV prevalence (5 or more per 1000 people) should be offered an HIV test by their GP practice when registering or when having a blood test if they have not had one in the last 12 months (National Institute for Health and Care Excellence, 2017). However, patients with higher risk should be identified and strongly encouraged to do frequent testing. High risks include men who have sex with men (MSM), HIV exposure if the contact is not on treatment, history of injecting drug use, a commercial sex worker or a client of a commercial sex worker, and sexual partners of those from a high risk geographical area (Sub-Saharan Africa, Caribbean, Russia/far Eastern Europe, South East Asia).
Patients from these high risk groups can also be offered PEP (post exposure prophylaxis) or PREP (pre exposure prophylaxis) from a sexual health clinic.
Hepatitis B risks should also be considered and hepatitis B vaccine offered if indicated. High risk groups include:
- Injecting drug use
- Commercial sex work
- Prisoner or ex prisoner
- High risk geographical area
- Household contact (if infectious)
- Sexual contact (if infectious)
- MSM
- Victim of sexual assault.
Finally hepatitis C risk should be considered. Those at high risk include taking part in certain sexual practices such as MSM having chemsex/unprotected anal sex/fisting/group sex, injecting drug use or a household contact.
Other sexual health issues
Health professionals should check with the patient if there are any other concerns that were not identified during the initial discussion. These may include psychosocial and psychosexual concerns, issues surrounding safety in relationships, and requests for general information about sexual and reproductive health and wellbeing (BASHH, 2013).
For women or patients assigned female at birth, useful information includes last cervical smear test, gynaecological issues, mammogram and other health promotion issues such as smoking cessation. Issues such as safeguarding, intimate partner violence and female genital mutilation (FGM) may be disclosed during the history taking and the health professional needs to be prepared for this. Finally, the consultation is an ideal environment to identify any risk behaviours and promote health promotion and a healthy sexual life free from infection and unintended pregnancy.
Conclusion
Sexual health is an essential component of a healthy life. Unfortunately, it is an area that can be neglected in a routine nursing or medical assessment, from either reticence by the patient or health professional. Initiating and taking a sexual history can be learnt in the same way as other history taking skills. Role play and practice will promote confidence in staff to include this in every consultation. It is only by normalising this part of life and including it in routine enquiry can we ensure positive sexual health outcomes are promoted and achieved.
KEY POINTS:
- Sexual health is an essential component of a healthy life
- Positive sexual health outcomes are seen as important to individuals and they have also been recognised by the government as a major public health issue
- The most important aspect of the environment for taking a sexual history is ensuring that the patient is assured of the confidential nature of the consultation
- It is only by normalising this part of life and including it in routine enquiry can we ensure positive sexual health outcomes are promoted and achieved
CPD reflective practice:
- How could you ensure your consultations are not disturbed when discussing potentially sensitive topics with patients?
- Reflecting on your practice, are you confident discussing sexual history with your patients? How could you improve this?
- How can you create a safe, welcoming environment for all patients?