Taking Sexual Histories: The Whys and Hows
It is important to tread carefully when taking a sexual history, not only because the answers are important but also because your client or patient will want to know why you need all that personal information. Since people can be uncomfortable when asked about their sexual history, providers must remain mindful of why each question is asked and what action will follow from the answers given.
Providers may need to obtain information for data collection purposes as required by funders, but they must first consider what the process means to clients. They should feel comfortable enough asking intimate questions to be able to help clients discuss risk behaviors and harm-reduction strategies, and to provide information. Whether collecting basic sexual history data or conducting in-depth research, they should be able to explain why they are collecting the information and how it will be used.
Taking a sexual history is an essential first step when providing contraceptive, reproductive, and HIV/STD counseling. It can screen for high-risk sexual behaviors, can identify sexual problems, and is an opportunity to provide information and support to clients. Statistics bear out that having sex is not rare for adolescent and young adult patients, or for any other patient who feels healthy enough. In a 2004 study of high school students, nearly 47% reported having had sexual intercourse. Between 800,000 and 900,000 females under the age of 19 become pregnant every year. Sexually transmitted diseases are also a major concern: chlamydia and gonorrhea incidence is highest among females aged 15-19 years old and males 20-24 years old.
Sex-related problems can lead to disease, illness, and even death; sexual abuse can cause sexual dysfunction and potentially contribute to substance abuse and mental illness; homosexual and transgender patients are at heightened risk for suicide and depression; and an estimated 50% of all pregnancies are unintended, leading to less prenatal care and a higher incidence of low birth weight, infant mortality, and other medical problems. Thus, understanding our clients' sex and sexuality is important in helping to decrease medical concerns linked to sexual behavior and sexual orientation.
Whom Should We Screen?
Many high-risk-taking behaviors begin in adolescence. In fact, 7.4% of teens have had sex before the age of 13, according to a 2004 study. Despite this, research has shown that clinicians are less likely to question younger adolescents than older adolescents about their sexual behaviors.
At the other end of the life cycle, some care providers assume that older adults are no longer sexually active and fail to assess their sexual health. But older adults who remain sexually active also remain at risk for sexually transmitted diseases (STDs), and they may be less forthcoming about any sexual problems they may be experiencing. In a study of sexual activity among older adults, 31% of men and 43% of women reported sexual dysfunction. In the 1989 Massachusetts Male Aging study, 52% of men aged 40-70 reported erectile dysfunction.
Unfortunately, studies show low rates of sexual health assessment of older adults by physicians and other clinicians. Time constraints, underestimation of patient risk, and embarrassment prevent some clinicians from conducting such assessments. Others may not believe that a sexual history is medically relevant to the purpose of a particular visit, while still others are unfamiliar with some sexual practices and avoid the topic entirely.
In the case of adolescent patients, many clinicians fear that if teens disclose sexual activity it will initiate a cascade of questions about pregnancy and STD risk. This may both lengthen the clinical visit and raise issues of confidentiality, parental involvement, and risk reduction. With older patients, some young physicians are uncomfortable asking questions about sexual dysfunction or satisfaction of people who may be their parents' or grandparents' age.
Do Patients Want to Be Asked About Sex?
Patients who do not discuss their sexual health with clinicians or health service providers often wish they had, and that the discussion had been part of a routine exam or intake process. A 1999 study assessed adolescents' views regarding sexual history taking and found that a majority of adolescents believe it is important to discuss sexual intercourse, contraception, pregnancy, unwanted sexual activity, and STDs with their doctor.
Are Clinical and Nonclinical Service Providers Trained to Obtain Thorough Sexual Histories?
Many graduating clinicians, including physicians, psychologists, and social workers, do not feel adequately prepared to evaluate sexual health problems. For example, studies have found that older physicians report they received less training on STD assessment than younger physicians. The situation is similar with non-clinical service providers.
Training in sexual history assessment may be increasing in medical school education, however, and students who have had sexuality/sexual health instruction report increased confidence in addressing this topic with patients. The American Medical Association has instituted efforts to increase physician comfort and sensitivity when assessing sexual history. A 2002 study reported that physicians who conduct sexual histories are also more likely to test patients for STDs, including HIV. Physicians and other healthcare providers are often the first point of contact for patients with sexual health concerns, and they can greatly affect sexual health and behavior in patients.
When Should a Sexual History Be Taken?
Often a sexual history is obtained when a patient or client presents with a specific symptom or complaint, such as vaginal discharge. But providers should also take advantage of routine check-ups, well visits, and preventive health visits, not only at STD or HIV testing sites. A sexual history may be obtained during the general medical history or during the taking of personal and social history. The Guidelines for Adolescent Preventive Services (GAPS) screening tool (available at ama-assn.org) assesses several risk factors, including sexual activity, and can be given to adolescent patients as a survey to be completed before the physician enters the room. Likewise, other assessment tools can be developed to assess the sexual histories of all patients or clients who might also be putting themselves at risk for HIV, HIV superinfection, or other STDs.
Elements in a Sexual History
The following is a list of elements that are essential to taking a good sexual history. There are many other sources of detailed examples of sexual risk assessment questions. This is meant solely as a summary of questions needed when gathering a sexual history:
Confidentiality: Establish a safe and comfortable environment in which to discuss personal health issues.
Patient concerns: Ask open-ended questions. This may help begin the discussion, but you may also have to ask about specific sexual problems. Many patients want to ask questions but won't unless given the opportunity.
Sexual orientation and preferences: It is important not to assume heterosexuality when obtaining a sexual history. This discussion can be prefaced by stating, "I ask these questions of all of my patients. Are you interested in men, women, or both? Are you having sex with men, women, or both?"
Age of "sexarche" (the onset of sexual activity): Younger adolescents who are in relationships with older partners know less about pregnancy prevention, HIV, and STDs, and are at greater risk of being coerced into unprotected sexual activity than those with same-age partners.
Types of sexual practice (oral, anal, vaginal): Elicit information about sexual behavior and types of sexual practice.
Date of last sexual intercourse: Important for pregnancy and contraceptive counseling, STD treatment and prevention, as well as knowing when to test for HIV.
Sexual partner assessment: The number of lifetime partners, number of partners within the preceding six months, the nature of the relationship (serial monogamy versus one-time events), and domestic violence screening.
Pregnancy: It is important to understand the patient's desires regarding pregnancy, so that counseling is consistent with his or her goals and information and advice is appropriate.
History of prior pregnancies: Again, this is helpful in contraceptive and reproductive counseling to identify risk and needs.
STD/HIV prevention practices: Inquire about condom usage (consistency, correct use, access), regular STD testing, number of partners, and reduction of risk behaviors.
STD symptoms: Recognize that patients may be asymptomatic, and use the assessment to provide education regarding HIV/STDs.
History of prior STDs: Eliciting this history provides an opportunity to discuss how to prevent future STDs and potential infertility and to assess HIV/STD risk. Assess the sex practices of those living with HIV as well as those who are HIV negative. Some clinical and nonclinical service providers assume that a person who is HIV positive is not engaging in unprotected sex, when STD and HIV statistics have shown the opposite.
Problems related to sexual intercourse.
History of sexual abuse: "Have you ever felt that you were forced to have unwanted sex?"
Asking all these questions at the initial visit might be overwhelming, depending on the reason for the visit; some of them may be reserved for subsequent visits. If patients or clients realize that a sexual history is part of a routine exam, they may be more comfortable raising questions or concerns in the future. Also, if patients see that their clinical and nonclinical service providers are sensitive and are comfortable asking these questions, they may view them as a resource for future sexual health information and discussions.
Luis Scaccabarrozzi is Director of Treatment Education at ACRIA.