The sexual history: A conceptual approach

Hofstra North Shore-LIJ School of Medicine

Biological Imperative, 2014
Joseph Weiner, MD, PhD
Please read the following outline, which will guide your thinking about
the dimensions of a sexual history.
Taking a sexual history is important for several reasons:
1) Enables risk assessment and improves risk reduction
a. Reduces or addresses teenage pregnancy
b. Treatment of sexually transmitted disease
c. Reduces high risk behaviors such as exchanging sex for
drugs
d. Uncovers circumstances of childhood, adult and geriatric
sexual abuse
2) Improves medication adherence
a. Sexual side effects of medications decrease medication
adherence
3) Addresses patient concerns that often are never discussed. This
is usually due to embarrassment of the patient and/or the
clinician.
4) Creating a broader differential diagnosis of the patients health
and well-being
a. Sexual difficulties can be caused:
i. Directly from medical problems such as diabetes,
atherosclerotic disease, or neurologic disease
ii. Indirectly from medical conditions such as pain or
weakness
iii. By medication side effects
iv. Directly or indirectly from substance abuse or
dependence (drinking, drugs, cigarettes)
v. By relationship issues
vi. From psychological issues such as depression or
anxiety
vii. By primary psychiatric issues such as paraphilias or
phobias
5) Thinking about the sexual history this way enables the clinician
to find naturally-occurring transitions in the patient encounter to
conduct a sexual history. See the end of this handout for a
discussion of gates this is a communication tool you can use
to seamlessly transition to the sexual history.
a. Transitioning from the history of present illness to a sexual
history

b. Transitioning from the past medical history to a sexual

history
c. Transitioning from the medication history to a sexual
history
d. As part of the social history

(next page)When should you take a sexual history? (Adapted from

Richard E. Green, MD The Sexual History, PowerPoint presentation)
1) Routine health maintenance for preventive primary care
2) Reproductive health care visits
3) Interval or acute visits in which sexual activity or practices may
contribute or be the cause of a complaint or a problem
i) Not just penile/vaginal discharge
4) Concerns of sexual assault/abuse
5) Whenever a patient wishes to discuss
Remember to utilize your skills in Function 1 when you explore a sexual
history (Adapted from Richard E. Green, MD The Sexual History,
PowerPoint presentation):
1) Ask Permission to explore a sexual history
a. Some people who take blood pressure medication
experience changes in their sexual functioning. Is it ok if I
ask you some questions related to your sexual
functioning?
2) Give permission to the patient to be open
a. Sometimes patients feel uncomfortable sharing concerns
about their sexual life. Thats normal. Id like to hear about
whats on your mind.
3) Discuss confidentiality
4) Stay non-judgmental
a. Use inclusive terminology [eg, say partner rather than
assuming someone is heterosexual]
b. Make no assumptions about someones sexuality,
preference for marriage or having children, desire to use
contraception or safer sex methods
c. Understand your biases!
5) Be professional/appropriate
a. Casualness can blur sexual boundaries in the interview
b. Coldness can shut a patient down
c. Empathy always goes a long way!
i. Reflect
ii. Legitimize
iii. Explore

(next page)

Once you transition to the sexual history, its crucial that you ask very
specific [closed-ended] questions. This is an essential learning point in
todays class.
Components of a Sexual History
Sexual activity. [What is sexual activity?]
Gender preference
Methods of protection
Number of current sexual partners
History of STDs
Any concerns or problems in the patients sexual life?

Questions for a Basic Sexual History

Sexual activity. [What is sexual activity?]
1. Are you currently sexually active? Have you ever been?
2. How many partners have you had in the past month? Six
months? Lifetime?
3. Do you participate in oral sex? Anal sex?
Gender Preference
1. For those patients who are sexually active, Are your partners
men, women, or both?
2. For those patients who are not sexually active, If you were to
have a sexual partner, would it be a man, woman or either?
History of STDs/HIV
1. Have you ever had any sexually related diseases?
2. Have you ever been tested for HIV? Would you like to be?
3. How do you protect yourself from HIV and other infections, like
herpes?
Methods of protection
1. Do you use anything to prevent pregnancy?
2. If yes, what method (s) do you use for contraception?
a. Are you satisfied with that method?
Any concerns or problems in the patients sexual life?

1. Do you have any questions or concerns about your sexual

functioning?
2. Women: Do you have any difficulty achieving orgasm?
3. Men: Do you have any difficulty obtaining and maintaining an
erection? Difficulty with ejaculation (or having an orgasm)? Do
you have difficulty feeling your orgasm when you ejaculate?
(Adapted from Am Fam Physician 2002;66:1705-12. Copyright 2002 American
Academy of Family Physicians.)

(next page)

Figure 1
Overview of when you can naturally transition to the sexual history
Elaborating
Elaborating
on the
the chief
chief
on
complaint
complaint
Obtianing
Obtianing a
a
full history
full
history of
of
present
present
illness
illness

Review
of
Review of
Systems
Systems
Opportunit
Opportunit
y
y to
to
discuss
discuss
Sexual
Sexual
History
History

Past
Past Medical
Medical
History
History

Social
History
Social History

Medicaltions
Medicaltions
with
with sexual
sexual
side
side effects
effects

Gates: A communication tool that allows you to transition to any topic

during a patient interaction.
What is a gate?
A gate is a point in the clinical discussion where the clinician has
to make a decision to continue the direction the conversation is going
in, or change it. Its like an open door either you walk through it or
you dont. The clinician can use four different transitional statements
to either keep an interview going in the same direction, or purposely

change the direction of the interview to explore other subjects. The

power of gates is that, once a clinician knows how to use them, he or
she gains much control over how an patient conversation flows.
The four kinds of gates and examples of how to use them:
1) A Natural Gate
a. A natural gate keeps the discussion moving in the same
direction.
b. Examples: Go on. Tell me more. What happened
then?
c. Another example of a natural gate is when the clinician is
quiet and nods, encouraging further discussion about the
same topic.
d. Another example: 18-year-old woman who presents for a
college physical exam.
i. Patient: Do any of the students ever come to college
to get away from things?
ii. Physician: What do you mean?
iii. Patient: Well, Ive had a bad time with my dad.
iv. Physician: Tell me more.
v. Patient: Its embarrassing.
vi. Physician nods without saying anything.
vii. Patient: Well, he would force himself on me. Maybe
I shouldnt talk about it. [She looks scared].
viii. This is scary to talk about. Its ok; Im here to help. I
would like to hear about what happened so we can
give you the support you need. Would it be ok if you
tell me more about what happened with your dad?
ix. Patient: OK
2) A Referred Gate
a. This is when the clinician refers back to an earlier part of
the discussion to clarify or further expand on a subject.
b. Example 1: A 40-year-old man presents with poor appetite,
weight loss, social withdrawal and tearfulness.
i. Physician: Is anything else bothering you?
ii. Patient: Yes. Im really tired all the time.
iii. Physician: OK. You mentioned before that youre not
sleeping well. Can you tell me about that? [Physician
refers back to an earlier part of the discussion to
expand upon the patients sleeping problems. This is
part of an exploration of pertinent positives for a
diagnosis of depression.]
c. Example 2: A 65-year-old man who was divorced two years
ago present with pain and discharge upon urination for the
past two days.

i. Physician: You mentioned before that youve been

dating for the first time since your divorce. May I ask
you about your sexual activity? [Physician refers
back to an earlier statement by the patient to use as
a transition to taking a sexual history.]
3) A Manufactured Gate
a. This is when the clinician uses creativity to manufacture a
transition to another area of discussion.
b. Example: 68-year-old woman with stable angina. She
presents for a scheduled regular checkup.
i. Physician: So if I understand you correctly, your heart
problems have made it hard for you to walk up more
than one flight of stairs without stopping to rest, but
things are stable in this regard. Is that right?
ii. Patient: Yes, thats right.
iii. Physician: Do your heart problems affect your life in
any other way?
iv. Patient: No, thats all.
v. Physician: Some patients tell me that heart problems
interfere with their sexual lives. Is this something
youve experienced yourself? [Physician creates a
transition to obtaining a sexual history.]
vi. Patient: Oh, well now that you mention it, yes
vii. Physician: Can you tell me about that?
viii. Patient: Yes, Im glad that you said that, because
there is something on my mind.
4) A Phantom Gate
a. This is when the clinician changes the subject of the
discussion without any connection to what preceded it.
Phantom means there is no gate.
b. Example 1:
i. Physician: Do you have any medical problems?
ii. Patient: I had a urinary tract infection once.
iii. Physician: Do you drink or use drugs? [There is no
connection to the previous response, as if the
physician is not listening.]
c. Example 2: A 25 year old man presents with nasal pain.
He has a long right pinkie nail, sniffles, is cachectic and on
exam he has nasal septal necrosis.
i. Physician: Beside the pain inside your nose, any
other pain or discomfort?
ii. Patient: No.
iii. Physician: Tell me about your cocaine use. [Although
there is no connection to the previous response, the
physician is being purposefully confrontational. Such
interventions should generally be avoided, because

they can be humiliating. They are also generally

unnecessary, as you will learn other ways to work
with people with drug and alcohol problems.]