Clinical Pearl: Taking a Sexual History by Armando Varela, MBA, MSN, AGACNP-BC, ENP-C, FNP-BC, CEN, CFRN on Behalf of the AAENP Diversity, Equity, and Inclusion Committee
When symptoms or exam findings are consistent with sexually transmitted infections (STIs), a sexual history should be collected. Creating a welcoming clinical environment for all patients should begin at first contact. Establishing your patient's name and pronouns, as well as their sexual orientation and gender identity is important. Gender identity is distinct from sexual orientation and is best assessed through a two-step technique, which includes questions about sex assigned at birth (female, male, or decline to respond) as well as current gender identity (female, male, transgender female, transgender male, gender diverse, additional gender category, or decline to answer).
Some patients may be uncomfortable discussing their sexual history, sex partners, or sexual behaviors. Patients may have been subjected to abuse or trauma in their life or while in the hospital. Nurse practitioners can benefit from training in a trauma-informed care approach, which can help them apply patient-centered, sensitive care to all encounters. Some patients may be victims of intimate partner abuse, and seeking medical help for medical problems may be their only way to find safe options.
Dialogue With Patient
• May I ask you a few questions about your sexual health and sexual practices? I understand these questions are personal, but they are important for your overall health.
• At this point in the visit, I 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 confidential unless you or someone else is being hurt or is in danger. Do you have questions before we get started?
• Do you have questions or concerns about your sexual health?
The Five P’s: Partners, Practices, Prevention of Pregnancy, Protection from STIs, and Past History of STIs
1. Partners
• “Do you have sex with men, women, or both?”
• “In the past 2 months, how many partners have you had sex with?”
• “In the past 12 months, how many partners have you had sex with?”
• “Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were still in a sexual relationship with you?”
2. Practices
• “To understand your risks for STIs, I need to understand the kind of sex you have had recently.”
• “Have you had vaginal sex, meaning ‘penis in vagina sex’?” If yes, “Do you use condoms: never, sometimes, or always?”
• “Have you had anal sex, meaning ‘penis in rectum/anus sex’?” If yes, “Do you use condoms: never, sometimes, or always?”
For condom answers:
• If “never”: “Why don’t you use condoms?”
• If “sometimes”: “In what situations (or with whom) do you use condoms?”
• “Have you had oral sex, meaning ‘mouth on penis/vagina’?”
3. Prevention of pregnancy
• “What are you doing to prevent pregnancy?”
4. Protection from STDs
• “What do you do to protect yourself from STDs and HIV?”
5. Past history of STDs
• “Have you ever had an STD?”
• “Have any of your partners had an STD?”
Additional questions to identify HIV and viral hepatitis risk include:
• “Have you or any of your partners ever injected drugs?”
• “Have you or any of your partners exchanged money or drugs for sex?”
• “Is there anything else about your sexual practices that I need to know?”
Finalizing the Conversation
The patient may have come up with information or questions that they were not ready to disclose earlier towards the conclusion of the interview session. Questions such as “What other concerns or questions regarding your sexual health or sexual practices would you like to discuss?” may allow the NP to use the encounter to combine risk-reduction education with sexual health goalsetting for healthy and safe sexual encounters. For patients at risk for STIs, encourage testing and positive comments regarding preventative techniques that the patient is willing or able to employ. Thank the patient for being upfront and honest.
Sources:
A Guide to Taking a Sexual History. (2022, April 18 ). Retrieved from CDC: https://www.cdc.gov/std/treatment/sexualhistory.pdf
Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3): 1-137.
The five Ps: Partners, prevention of pregnancy, protection from STIs, practices, and past history of STIs. (2022, April 18). Retrieved from UpToDate: https://www.uptodate.com/contents/image?imageKey=ID%2F61677
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