Taking a Sexual History

Introduction

A sexual history is taken whenever a patient presents with symptoms that might be caused by a sexually transmitted infection (STI), when they request an STI screen or contraception, or when a clinical situation raises the possibility of an undisclosed sexual health need, such as unexplained pelvic pain, a targeted vaccination discussion, or a safeguarding concern.¹

It is one of the histories students find hardest to practise because it asks about behaviour rather than symptoms, and because doing it badly - through embarrassment, assumption or leading questions - produces a history that is both incomplete and inaccurate. The skill is to be direct, systematic and unembarrassed, so the patient feels able to answer honestly.

The UKMLA expects candidates to structure this history reliably under exam conditions, know when a chaperone and examination are required, and recognise the safeguarding thresholds that apply to under-18s and vulnerable adults.²

Setting the scene

Privacy and confidentiality must be established before any sensitive questions are asked. Consultations should take place somewhere the conversation cannot be overheard, with any accompanying friends, partners or family members asked to step out - tactfully, but explicitly - since a partner's presence can suppress disclosure of other partners, violence or coercion.

Explain the purpose of the questions and the limits of confidentiality before starting: information will not routinely be shared with anyone else, including a spouse, employer or (for older teenagers) parents, but confidentiality can be broken if there is a serious risk of harm to the patient or others, such as evidence of abuse or exploitation. Stating this up front, rather than after a difficult disclosure, builds trust rather than undermining it.

Presenting complaint

Begin as with any history: ask about the presenting symptom in the patient's own words, then explore it using the standard framework of onset, duration, character, associated symptoms, and what prompted them to seek help now.

Common presenting complaints in sexual health include vaginal or urethral discharge, dysuria, genital ulceration or lumps, pelvic or testicular pain, intermenstrual or post-coital bleeding, and rashes. Some patients present with no symptoms at all, requesting screening after a new partner, a partner's positive result, or simply as a routine check.

• Discharge: colour, consistency, odour, amount, and whether it is new
• Pain: site, radiation, relationship to intercourse or urination
• Skin change: ulcers, blisters, warts or rash - painful or painless, single or multiple
• Bleeding: intermenstrual, post-coital, or post-menopausal bleeding all warrant specific follow-up
• Systemic symptoms: fever, joint pains, or a rash elsewhere can suggest disseminated infection

The sexual history

Once the presenting complaint is explored, the sexual history proper follows a systematic structure, sometimes remembered as the '5 Ps': partners, practices, protection from STIs, past history of STIs, and prevention of pregnancy.³

Partners

Establish the timeline of recent sexual contacts, working backwards from the most recent partner. For each partner within the relevant window (usually the last three months, extended if the presenting infection has a longer incubation, such as HIV or syphilis), ask about the timing of contact, the gender of the partner, whether the relationship is ongoing or one-off, and whether the partner has any known symptoms or diagnoses.

Practices

Ask specifically which parts of the body were involved - vaginal, anal and oral sex each carry different infection risks and determine which anatomical sites need to be swabbed. Avoid assuming that heterosexual identity excludes anal sex, or that men who have sex with men do not have vaginal partners. Ask about the receptive or insertive role during anal sex, since this affects site selection for testing and, in HIV-negative men who have sex with men, the relevance of pre-exposure prophylaxis (PrEP).

Protection

Ask about condom use for each type of intercourse, and whether use is consistent or occasional. Establish whether the patient uses any other barrier method, and whether they have ever had, or are currently taking, HIV pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP).

Past history

Ask about previous STIs, when they were diagnosed and how they were treated, previous STI screens and their results, HIV and hepatitis B/C status if known, and vaccination history for hepatitis B and human papillomavirus (HPV). A history of a previous STI is itself a risk factor for another.⁴

Pregnancy and contraception

For patients who could become pregnant, establish the date of their last menstrual period, current contraceptive method and adherence to it, and whether pregnancy is currently wanted or being avoided. This is relevant both because some STI treatments are contraindicated in pregnancy and because an unplanned pregnancy risk may need addressing at the same consultation, for example with emergency contraception.

Further history

Complete the history with the standard components adapted to context: relevant past medical history (immunosuppression, diabetes, pregnancy), drug history including allergies (important before prescribing antimicrobials), and a targeted social history covering alcohol and recreational drug use, including chemsex practices where relevant, as these increase both infection risk and the complexity of consent.

Ask directly about any history of sexual violence or coercion, and screen for domestic abuse where the clinical picture raises concern. These questions should be asked of the patient alone, without a partner or family member present, using a validated approach if the department has one, such as the HARK screening tool.⁵

Safeguarding and special groups

Sexual history taking in under-18s requires an assessment of Gillick competence: whether the young person has sufficient maturity and understanding to consent to the consultation and any treatment without parental involvement. The Fraser guidelines specifically govern contraceptive and sexual health advice to under-16s, and require that the clinician is satisfied the young person understands the advice, cannot be persuaded to involve their parents, is likely to continue having sex regardless, and that their physical or mental health would suffer without treatment, with treatment being in their best interests.⁶

Where any of these are present, involve a named safeguarding lead and follow local safeguarding policy; do not rely on the sexual history consultation alone to manage the disclosure.

Examination

Examination is offered when clinically indicated by the presenting complaint - for example, genital examination for discharge, ulceration or lumps, or abdominal and pelvic examination for suspected pelvic inflammatory disease. It is not a routine part of every sexual health consultation, particularly asymptomatic screening, where self-taken swabs are often sufficient.

A chaperone must be offered for any intimate examination regardless of the sex of the clinician or patient, and the offer and outcome documented. Explain what the examination will involve and obtain explicit verbal consent before proceeding.

Investigations

The history determines which samples are needed. A full STI screen typically includes nucleic acid amplification testing (NAAT) for chlamydia and gonorrhoea from the relevant sites (vulvovaginal or first-catch urine, rectal, and pharyngeal swabs as indicated by reported practices), serology for HIV and syphilis, and, depending on risk, hepatitis B and C serology.³

Self-taken swabs are validated and preferred by many patients over clinician-taken swabs when no examination is otherwise indicated. Point-of-care testing is increasingly available for HIV and syphilis, giving a result within the same consultation.

Documentation and partner notification

Document the history systematically, including explicit statements about consent to examination and any safeguarding assessment made. Where an STI is diagnosed, partner notification (contact tracing) should be discussed: current or recent partners are informed of their exposure so they can be tested and treated, either by the patient themselves (patient referral), by the clinic contacting the partner without naming the index patient (provider referral), or through a combination of both.⁷