Levels of evidence (I-IV) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
The Environment for Sexual History Taking
A welcoming, comfortable, confidential physical environment is likely to encourage openness and candour when discussing sensitive issues, such as sexual behaviour. To facilitate this, the following measures should be adopted:
- Services may find that clearly displaying literature that stresses confidentiality of the clinic and the non-judgemental nature of assessment improves the consultation.
- Clinic administration procedures (storage/visibility of clinic files and clinic lists, etc.) should be designed to ensure that confidentiality is maintained between patients.
- Clinics should decide on the most appropriate way of calling patients for consultations such as calling by first name, full name, or clinic number. Care should be taken to confirm that patient identification is correct.
- Consultations should take place in private settings and in sound-proofed room.
- Students and observers should be present only with the patient's consent, and the wishes of the patient should be respected if the presence of a student or observer is declined. However, the patient should be offered a chaperone for any intimate examination.
- Requests for clinician gender on the basis of culture, religion, or personal preference should be accommodated where possible and pathways to other services should be in place to support patients whose preferences cannot be accommodated.
Recommendation: Sexual history taking should take place in a confidential, private environment. (IV, C)
Recommendation: All clinics should have a confidentiality policy that should be displayed in the waiting area or otherwise made available to patients. (IV, C)
Recommendation: All patients should be offered a chaperone for any intimate examination in accordance with General Medical Council (GMC) guidance. (IV, C)
Recommendation: All patients should be offered a clinician of their preferred gender where possible. (IV, C)
Management of Sexual Contacts
The utmost care should be taken to preserve the confidentiality of patients and their sexual contacts during the consultation. This can be difficult in certain situations; for example, where a patient attends as a contact of an infection but does not know the reason for their attendance. The index patient must not be identified. The clinician must not confirm the identity of the index patient, even if raised by the patient, or reveal any details about their attendance (or non-attendance) or clinical condition. Care should also be taken to avoid having third-party information in a form that might be easily viewable on an electronic patient record in case a patient might see this on the computer screen.
Clinic Access and External Communication/Advertising
Although many patients who are referred to or refer themselves to sexual health/UK genitourinary medicine (GUM) clinics will expect to be asked sensitive questions regarding their sexual behaviour, this may not always be the case.
Clinic advertising, including the use of Web sites and clinic leaflets displayed elsewhere (e.g., general practitioner [GP] surgeries, contraceptive clinics, schools, colleges, etc.), should explain the role of the clinic and what should be expected during a consultation. This may improve the acceptability of asking questions which may otherwise be perceived as being intrusive.
Recommendation: Clinic literature/advertising leaflets should include sections regarding the need to take an appropriate sexual history. (IV, C)
The ability to communicate effectively is required of all clinicians and may be important in improving health outcomes. The initial contact with a patient can be particularly important for obtaining an accurate sexual history and particular attention should be paid to:
- The initial greeting to the patient
- Maintaining eye contact (if culturally acceptable) and using appropriate body language
- Initiating a consultation with open questionsa followed by exploration of initial concerns and more closed questions as the consultation continues
- Explaining the rationale for some of the questions asked
- Consider the use of sexually explicit language within the sexual history consultations and use language that is clear, understandable, and with which both clinician and patient are comfortable
- Awareness of the signs of anxiety and distress from the patient
- Recognizing non-verbal cues from the patient
aExamples of open questions include 'how can I help you today?' or 'what brings you here today?'.
Particular issues that need to be covered in training clinicians in sexual history taking include addressing attitudinal issues of the clinician to sexual behaviour and specific knowledge about the range of sexual consultations that can be undertaken. Although there are well-recognised models of best practice in communication skills training, assessment of the quality of communication skills is complex. A variety of different mechanisms for assessing communication skills have been proposed including patient questionnaires and direct or video-recorded consultation with patients or actors.
Recommendation: Assessment of clinician communication skills should form part of the assessment of service quality. (IV, C)
All sexual health clinics should have policies in place to address the communication needs of specific patient groups, including patients whose first language is not English, people with hearing or learning difficulties, and people who cannot read. Sign language interpreters; foreign language interpreters; access to telephone interpretation services; use of communication aids, including Web sites; working with local support organisations; and dedicated clinic times for patients with communication problems, are all strategies that may need to be adopted.
Recommendation: All sexual health clinics should have policies in place to address the needs of patients with whom there are communication problems, including illiteracy. (IV, C)
Components of a Sexual History
The appropriate detail of the sexual history will vary between services but should allow:
- A careful assessment of symptoms to guide the examination and testing
- An exposure history to identify which sites need to be sampled and the sexually transmitted infections (STIs) to which the patient may be at risk
- An assessment of contraception use and risk of pregnancy
- Assessment of other sexual health issues (also allowing a discussion of psychosexual problems)
- Assessing human immunodeficiency virus (HIV), hepatitis B and C risk for both testing and prevention
- Assessment of risk behaviours, which will then facilitate health promotion activity including partner notification and sexual health promotion
A summary of suggested sexual histories in different testing scenarios is given in Tables 1-4 in the original guideline document.
Reasons for Attendance
It is best to start the sexual history with less intrusive questions regarding presenting concerns and symptoms before asking more sensitive questions regarding sexual behaviour. After the reason for attendance has been identified, the clinician should ask closed questions to identify specific GU symptoms. All clinicians will ask further questions regarding the duration and nature of any reported symptoms. Some patients may report that a partner has an STI and it is important to clarify the nature of the infection and contact as accurately as possible.
It is uncertain whether a symptom review in patients not reporting symptoms is useful. However, many GUM clinicians ask about specific genital symptoms in case this reveals overlooked or ignored problems. Many clinicians would routinely ask women presenting to GUM clinics questions relating to the following symptoms:
- Unusual vaginal discharge
- Vulval skin problems
- Lower abdominal pain/deep dyspareunia
- Unusual vaginal bleeding, including post-coital and inter-menstrual bleeding
Many clinicians would routinely ask men presenting to GUM clinics questions relating to the following symptoms:
- Urethral discharge
- Genital skin problems
- Testicular discomfort or swelling
- Peri-anal/anal symptoms (in men who have sex with men [MSM])
The more detailed parts of the sexual history outlined below may be identified during the initial discussion with the patient. They will, however, more often be dealt with while asking more 'closed' questions later in the consultation.
Services primarily undertaking STI screening may undertake a brief core sexual history to establish whether someone is at any risk of STIs and take a more detailed history if the STI screen is positive.
Using 'bridging' questions, which link general lifestyle questions to sexual history questions or 'universal' questions (questions which are explicitly asked of all patients), may also help when introducing sensitive questions. The need to ask important questions regarding risk taking (such as same sex partners and injecting drug use), which some patients may find offensive, should be clearly explained to all patients.
It is important to ascertain the type of sexual contact/sites of exposure in both MSM and heterosexual men and women in order to be able to identify which sites need to be sampled. In women who report oral or anal sex, up to 25% of chlamydia or 35% gonorrhoea infection would be missed if the pharynx or rectum were not sampled, as infection may be found in these extra-genital sites only. In addition, a similar proportion of infection is present in both genital and extra-genital sites. Azithromycin is reported to be as little as 80% effective in eradicating extra-genital chlamydia infection with doxycycline being much more effective. Therefore, if extra-genital swabs are not taken from a person at risk, the infection may go unrecognised and untreated or the patient may be given inadequate antibiotic therapy. This would leave the patient still infected and acting as an infection source to partners as well as potentially being at risk from complications of the infection. A history of the types (sites) of sexual contact is also recommended in the International Union against Sexually Transmitted Infections (IUSTI) European guidelines for the organisation of a consultation for STIs, 2012.
Last Sexual Contact (LSC)
All individuals being assessed for risk of STIs should be asked about:
- The gender of partner(s)
Rationale: To identify MSM in order to offer rectal and pharyngeal samples, undertake hepatitis screening and vaccination
- The type of sexual contact/sites of exposure (oral, vaginal, anal) (II, A)
Rationale: To identify which sites need to be sampled
- Condom use/barrier use (and whether properly used)
Rationale: Facilitation of condom promotion and risk assessment
- The relationship with the partner (live-in, regular, casual partner, etc.), duration of the relationship and whether the partner could be contacted
Rationale: To facilitate partner notification
- The time interval since the last sexual contact
Rationale: To inform the patient of any need for repeat testing if still inside 'window' periods for infection detection and to help in assessing the need for emergency contraception or post-exposure prophylaxis for HIV infection
- Any symptoms or any risk factors for blood-borne viruses (BBV) in the partner including known or suspected STIs, injecting drug use, previous homosexual sex (for male partners) and any other risk of sexual infection
Rationale: To identify STI or BBV diagnosis, or symptoms suggestive of an STI, in partners
Previous Sexual Partner, if Less Than Three Months Previously (Before Partner of LSC, Last Partner Change)
All individuals should be asked about the:
Look-back Interval for Recording Information About Partners
Other Components of the History
Recommendation: All individuals should be asked about a history of STIs and HIV. (IV, C)
- The diagnosis and approximate date of diagnosis should be recorded. All patients should be asked about a history of previous STIs (including HIV).
- Patients with a history of previous syphilis should have the date of diagnosis, stage of syphilis, treatment given, and clinic of treatment recorded.
Rationale: To allow the interpretation of positive syphilis serology in patients with a previous history of syphilis
- Past medical and surgical history
Rationale: To identify conditions that may be associated with or influence the management of STIs
- Drug history and history of allergies. All patients should have a history of current medication taken, including over-the-counter remedies, and be asked for history of previous allergies, particularly to antibiotics
Rationale: To identify medication that may interfere with sexual function, to identify potential drug interactions and if drugs cannot be given safely
- Alcohol and recreational drug history. May be indicated particularly in cases where disinhibition may be a factor in risk taking behaviour and in young people taking risk
Rationale: Alcohol and recreational drugs are a major factor in sexual risk taking. Screening tools such as FAST and Alcohol Use Disorders Identification Test (AUDIT) are quick and simple to do. Some services will screen and undertake Alcohol Brief Interventions.
- For women born after 1995, a human papillomavirus (HPV) vaccination history
Rationale: To facilitate access to vaccination of those eligible if not started or not completed
Contraceptive and Reproductive Health History
Increasingly, sexual health services are provided as integrated STI/contraception clinics. The contraception and reproductive health history may therefore vary according to whether the service primarily has an STI testing and treatment focus, or is providing an integrated service.
Recommendation: All women should be asked about the following (IV, C):
- Contraceptive use and compliance
- Last menstrual period and menstrual pattern
- To identify pregnancy or pregnancy risk
- To avoid drugs contraindicated in pregnancy
- To provide post-coital contraception if indicated
- To give advice regarding contraception if necessary
- To exclude contraceptive methods as a cause of irregular bleeding
- To avoid prescribing enzyme inducing drugs in conjunction with low dose hormonal contraceptive methods (except for injectables)
- Previous pregnancies including outcomes and complications
Rationale: Part of the assessment of reproductive and sexual health, including any impact on the current presentation and the identification of children who may be affected by STIs
- When the last cervical cytology was taken (if aged 25 years or over in England, Northern Ireland, and Republic of Ireland or 20 years or over in Scotland and Wales), the result, and if ever abnormal (IV, C).
Rationale: To determine whether to recommend cervical cytology
The Integrated Contraception and Sexual Health Service
In the integrated contraception and sexual health service the history will generally be more detailed in the following areas:
For female patients:
- Identify unmet contraceptive need, including the need for emergency contraception and eligibility for different contraceptive methods. The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) shows areas that should be reviewed with regard to identifying risks associated with hormonal contraceptive methods.
Rationale: Review of contraceptive need provides opportunities for information giving, motivational interviewing, and provision of contraception
- Current contraceptive use, any difficulties with the current method, the correct use of, and satisfaction with the method used (including condoms and natural methods), and the need for on-going supplies
Rationale: Review of current contraception may provide opportunities to improve concordance and satisfaction, and unscheduled vaginal bleeding or pelvic pain may be a side-effect of contraception. The Faculty of Sexual and Reproductive Healthcare guidance deals with unscheduled vaginal bleeding in women using hormonal contraception, including points to cover in the clinical history, as well as management.
- Identifying any unintended pregnancy risk and the need for pregnancy testing
Rationale: Recognising unwanted pregnancy allows for the provision of support and improves access to termination of pregnancy services.
- History of abnormal vaginal bleeding
Rationale: Unusual vaginal bleeding may be due to cervical pathology and may prompt the offer of cervical examination and need for urgent colposcopy clinic referral.
- Menstrual pattern, including any change in pattern
Rationale: Ascertaining the menstrual pattern is important for determining pregnancy risk, decision-making for European Commission (EC) provision, assessment of pelvic pain, and in supporting the diagnosis and referral of women with polycystic ovarian syndrome, other gynecological disease, and the post-menopause state where necessary.
- Mood change associated with the menstrual cycle
Rationale: Provision of support and access to referral pathways for management of possible premenstrual syndromes
- Family history
Rationale: To determine eligibility and contraindication for contraception according to UKMEC
- Smoking history
Rationale: Modifiable risk factor for cervical cancer and alters UKMEC status of combined hormonal contraception
- HPV vaccination history
Rationale: To facilitate access to vaccination of those eligible if not started or not completed
For male patients:
- Discussion with male patients about contraception, including contraceptive use by female partners
Rationale: Provides opportunities for information giving, including male methods of contraception, motivational interviewing, and may facilitate the use of services by female partners
- Identification of unrecognized lower urinary tract symptoms in men, particularly men aged >40 years. These include symptoms related to storage, voiding, and post-micturition
Rationale: Recognition of these symptoms may aid in the assessment of other symptoms in men presenting to sexual health clinics. This may lead to detection of disease including diabetes mellitus, benign prostatic enlargement and prostatic cancer, and provide opportunities for information giving, support, and access to referral pathways. National Institute for Health and Clinical Excellence (NICE) guidance provides the areas to cover in the clinical history, as well as management.
Female and male patients:
- Identification of unmet need with regard to difficulties with sexual performance and satisfaction. Presentation related to psychosexual problems are common in women and men in sexual health settings. In men, erectile dysfunction is associated with increased acquisition of STIs and non-use of condoms
Rationale: Provides opportunities for information giving, support and provision of referral pathways
- Recognition of gender-based violence (GBV) or intimate partner violence (IPV). GBV/IPV is associated with sexual assault, STIs, and unintended pregnancy as well as other risk factors
Rationale: Provision of support and access to referral pathways. The Department of Health has produced a toolkit to help practitioners manage IPV. NICE is producing Public Health guidance on preventing and reducing IPV. Although there are no validated screening questions for IPV in sexual health settings, the brief questions in the pilot draft produced by the Camden Multi Agency Domestic Violence Forum are widely recommended for use. Routine enquiry about current and historic gender-based violence aims to detect men and women who may be at risk of further ongoing violence and alerts practitioners to consider their safety. This is now mandatory in sexual health services in Scotland.
Risk Assessment for Blood-borne Viruses
Recommendation: All individuals should be asked about the following (IV, C):
- Current or past history of history of injecting drug misuse; sharing of needles, syringes, or other drug preparation, and injecting equipment ('works'). To also include discussion of injecting drug misuse in sexual partners (IV, C)
Rationale: To identify the need for hepatitis B, hepatitis C and HIV testing and hepatitis B vaccination
- Sex with a partner from or in a country with a high HIV prevalence
Rationale: To identify sexual partners at higher risk of HIV (IV, C)
- HIV testing history
Rationale: To determine whether HIV testing is necessary
- Men should be asked if they have ever had sexual contact with another man and women asked about previous bisexual male partners
Rationale: To identify the need for hepatitis B and HIV testing and hepatitis A and B vaccination
- Hepatitis B risk (including patient's country of birth, sex with sex workers, partners from or in high prevalence countries, MSM, and injecting drug users) and hepatitis B vaccination history (IV, C)
Rationale: Identification requires serological testing of hepatitis B and vaccination.
The following risks may be also asked about, where appropriate:
- Men and women may be asked whether they have ever exchanged money in return for sex (IV, C)
Rationale: To allow appropriate health promotion and hepatitis B testing and vaccination
- Other risks: non-use of condoms associated with erectile dysfunction, repeated condom breakage or slippage, participation in group sex events, use of alcohol and non-injecting drug use, use of social networking Web sites to find sexual partners, use of high risk venues, receptive fisting, traumatic sexual practice, and use of sex toys
Rationale: To identify specific behaviors, associated with increased STI acquisition, that may provide opportunities for safer sex and substance use information-giving and support, and direct the offer of tests
- Medical treatment/tattooing where sterility cannot be guaranteed
Rationale: To establish the need to test for nosocomial BBV acquisition
Closing the Sexual History
Recommendation: After the sexual history is completed, the clinician should (IV, C):
- Check with the patient that they have no other concerns that have not yet been discussed. These may include psychosocial concerns, issues about 'coming out', safety in relationships, information about STI transmission
- Explain the need for, and nature of, a clinical examination and tests
- Give the patient the option of a chaperone for the examination
- The method of communicating results to the patient should be agreed
Sexual health clinics have historically maintained their own record sets and record systems. That does not release them from following local and national guidance and law about records retention, data protection, and subject access requests. Particular care is needed in sexual health services regarding the recording (and thus potential disclosure) of third-party information (where a person who is not the patient discloses something about the patient). Services that make use of general health records (e.g., as part of a hospital outpatient service or electronic system) need to consider who may access that record and ensure patients are informed about confidentiality arrangements.
Recommendation: It is recommended that (IV, C):
- The record keeping of a sexual history should be in keeping with national standards of practice.
- Services should agree minimum data sets taking into account local and national health priorities and reporting requirements. Services should audit record-keeping for completeness against this.
- Sexual health records should be processed and stored in accordance with local and national guidance and law. Third-party data should be clearly indicated.
The Use of Standard History Proformas
Many services record the sexual history on proformas with a locally-agreed dataset. These may:
- Assist timely record keeping
- Make history taking more systematic
- Reduce the chance of omitting important pieces of information
- Facilitate audit
Services should consider the range of data items in the light of their local and national health priorities and needs. For example in Scotland, routine enquiry about gender-based violence was mandated in sexual health services in 2008 and a national minimum data set for all sexual health services was agreed in October 2011 to replace the STISS coding system (see Appendix 2 in the original guideline document).
Electronic Patient Records (EPR)
Many services now use clinical information systems. These range from simple demographic registers to fully-fledged bespoke sexual health paperless electronic record systems (see Appendix 3 in the original guideline document). Services implementing electronic record systems need to ensure staff are trained in their use and are aware of their responsibilities for data protection. The Department of Health (DH)/Royal College of General Practitioners (RCGP)/British Medical Association (BMA) produced guidance for paperless working for GPs in 2011, with chapters on data accuracy and moving to paperless practice, including tips on how to consult while using a computer. This is relevant to sexual health clinic settings. There are also several publications now that demonstrate the advantages of EPR in the sexual health setting.
Some services now offer computer-assisted self-interviews (CASI) or computer-assisted personal-interviews (CAPI) to replace some of the routine 'pen and paper' face-to-face clinical interview. Evidence shows a CASI approach to be acceptable in a sexual health setting with similar consultation times and few patients declining to answer risk questions. Although CASI may yield additional disclosures in sensitive question areas, some evidence shows staff may not act on this information and that overall STI or HIV detection rates may not improve.
Seeing Patients Who Are Under the Age of 16 Years
There is a specific national guideline for children and young people. The following is a brief description of some of the important issues.
Recommendation: All patients less than 16 years of age should have their competency to consent to history taking, examination and treatment assessed and this assessment should be documented in the clinical notes. (IV, C).
Where there are any concerns regarding a child's safety, there should always be serious consideration given to liaison with the local safeguarding children team.
Answers to the following additional questions may flag up the need for further assessment and liaison with the local safeguarding children team:
- Whether parents/carers are aware of the child's sexual activity
- Whether parents/carers are aware of the child's attendance at the clinic
- Whether the child has ever had non-consensual sexual contact
- Age of sexual partner(s)
- Vulnerability (e.g., self-harm, psychiatric illness, drug or alcohol misuse, where there is an imbalance of power, e.g., youth workers/teachers, or grooming is likely)
Where children under the age of 13 years report sexual activity, this should be discussed with a senior colleague and there is an expectation that this will be discussed in confidence, with the local child protection lead. Reporting to social service and the police may be indicated but is not mandatory. In Scotland, the guidance is that 'practitioners should automatically share child protection concerns' for children who are having or have ever had sex when aged under 13.
Taking a Sexual History in the Outreach Setting
Outreach clinics, either run by GUM clinics or which have been devolved to other providers, bring sexual health services out of traditional settings.
Recommendation: The following factors should be considered when taking a sexual history in an outreach clinic (IV, C):
- The structure of the sexual history taken should be adapted to the needs of the community or client group being served in order to be inclusive and to promote sexual well-being regardless of culture, gender, age, sexuality and sexual lifestyle. For example, more focused discussion of contraception in areas of high teenage pregnancy rates or the additional needs of MSM.
- All services should be provided in a comfortable environment that supports the patients' confidentiality and dignity.
- Specific consideration should be given to security measures for the protection of staff working in remote sites or in out-of-hours services.
- Chaperoning for the medical interview and examination should be available and offered to all patients.
- Clinical governance arrangements for outreach clinics should be robustly maintained for both National Health Service (NHS) and non-NHS providers.
- The use of a proforma for history taking is recommended and its correct use should be audited regularly.
- The scope of practice of the service should be clearly defined and referral pathways established for patients presenting with symptoms beyond this scope; for example: ectopic pregnancy; sexual assault; HIV post-exposure prophylaxis.
- Information governance arrangements must be clearly defined, as the secure transfer of information is essential for good care. Protocols should be in place to guide the secure storage, transfer and relevant sharing of information. The use of an electronic patient record is recommended as this is more secure and minimizes the transfer of paper records.
Levels of Evidence
Ia: Evidence obtained from meta-analysis of randomised controlled trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies such as comparative studies, correlation studies, and case control studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
Grading of Recommendations
A (Evidence Levels Ia, Ib)
- Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.
B (Evidence Levels IIa, IIb, III)
- Requires availability of well-conducted clinical studies but no randomised clinical trials on the topic of recommendation.
C (Evidence Level IV)
- Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities.
- Indicates absence of directly applicable studies of good quality.