Taking a sexual history
This section focuses on a key skill we all need in our varied jobs - how to take a sexual history. This doesn't mean that you have to be an expert on sexual health - but it is important to recognise needs and help to 'signpost' patients and clients to the services that can best meet those needs.
The key learning points are:
- Good communication skills are essential to make the client feel at ease when discussing sexual health issues.
- There is a wide spectrum of 'normal' sexual behaviour.
- A sexual history can identify those clients at risk of sexually transmitted infections, in order that they can receive appropriate advice/screening.
- An inadequate or incomplete sexual history can result in clients receiving inappropriate care, or care which does not meet their needs.
The purpose of taking a sexual history is to encourage high standards of sexual risk assessment. No care plan, intervention or advice can be safely given unless it is based on a comprehensive history and assessment of the individual. The components of sexual history taking are presented below: consider them in the light of your skills and experience - is this a task you are competent to undertake? For instance, check if there are parts of this history taking that you are unsure about, and consider whether you have enough experience to engage with your patients and clients in this process. Referral to a more experienced colleague or service is always appropriate if a person requires help which you do not feel competent to give.
View the video about Debbie and think about how you would deal with this situation if you were the member of the nursing staff involved. To read a transcript of the audio in this video, select the link Debbie's story (Word 15KB).
In the video, Pat did many things right - she checked on child protection issues, tried to engage Debbie's parent in the process, and asked relevant questions about timing, contraception and menstrual cycle. Unfortunately she made assumptions about Debbie's understanding, and an assumption that Debbie had had full penetrative vaginal intercourse, which shows that when it comes to sexual history taking, nothing should be assumed or taken for granted! With this case study in mind, now consider at the key learning points about history taking in more detail.
The environment
The first consideration is the physical environment. Think about the place that you work in, and how it matches the criteria below. If you think there are some improvements that could be made, you may wish to use the 'Action plan' template (PDF 26KB) - [see how to access PDF files] to document these ideas and then save or print a copy to share and plan your ideas with colleagues. You may also wish to upload your action plan to your e-Portfolio as evidence of your learning.
Communication skills
Good communication skills are important for any consultation. In sexual health, the following are particularly helpful:
- a polite, friendly welcome and introduction with eye contact
- explain why very intimate questions are about to be asked
- asking general questions first, then sensitive or potentially embarrassing ones after rapport is well established
- starting with open questions, e.g. "How can I be of help?", and exploration of initial concerns
moving on to more closed questions to confirm details (e.g. "Is it painful when you pass urine?") - awareness of verbal and non-verbal cues from the person, and whether they appear to be distressed, or anxious
- being clear about confidentiality, consent, what they think is the problem and what you think is the problem
- sharing agreement and decisions on what should happen next
- friendly closure, repeating any key message or providing the information they need
- accurate record keeping to ensure other health care workers can participate in care provision.
Two common communication difficulties are:
- the need for interpreters - think about how you would access one for someone who doesn't speak English, or is deaf and uses sign language
- the use of slang terms for body parts, sexual acts etc. These vary with age, culture and local dialect - what terms are commonly used in your region?
Components of a sexual history
You should be selective about asking the questions that are relevant at that time - it's not necessary or appropriate to go through all of these with everyone who presents with a sexual health need.
Also, consider early on whether a referral to a specialist clinician is likely - the patient or client may not want to go through everything several times, and it may be appropriate to refer them when you are sure it is necessary, rather than to keep asking questions you cannot act on. Explore the activity below to see the key questions asked when taking a sexual history and the reason for asking them. This is based on the British Association for Sexual Health and HIV (BASHH) 2006 National Guidelines - consultations requiring sexual history taking and a link to this is provided in the 'Useful resources' section.
A final word: emergency contraception
Emergency contraception refers to contraceptive methods which if taken after sexual intercourse may prevent pregnancy. They are used when unprotected sex has occurred, or when an existing method cannot be relied on - for instance, if a condom has split or come off. There are two types of emergency contraception:
- Emergency hormonal contraception (EHC) is the preferred term for what used to be called the 'morning after' pill. There is a progestogen-containing pill which has to be taken within 72 hours of sexual intercourse and can be bought from a pharmacist without a prescription for approximately £30. There is also uilpristal acetate which can be taken up to five days after unprotected sex, but it needs to be prescribed. The earlier EHC is taken after sex, the more likely it is to be effective.
- An intrauterine contraceptive device (IUCD), can be inserted into the uterus up to five days after unprotected sex.
Both EHC and the IUCD are available for free from NHS clinics which provide a contraceptive service, e.g. doctors' surgeries and sexual health clinics.