VOL: 101, ISSUE: 44, PAGE NO: 28
Cindy Gilmour, MSc, RGN, is nurse practitioner, West London Centre for Sexual Health, Charing Cross Hospital, LondonSince the 1990s the UK has seen an overwhelming increase in the rates of sexually transmitted infections (STIs) and HIV, unintended pregnancies and high-risk behaviour. Between 1995 and 2000 infections such as chlamydia, gonorrhoea and syphilis increased by 107 per cent, 102 per cent and 145 per cent respectively (Health Protection Agency, 2001). In response, the Department of Health (2001) produced a national strategy for sexual health and HIV, with the aim of reducing transmission and prevalence rates of STIs and HIV, reducing unintended pregnancies and reducing the stigma associated with STIs and HIV.
Since the 1990s the UK has seen an overwhelming increase in the rates of sexually transmitted infections (STIs) and HIV, unintended pregnancies and high-risk behaviour. Between 1995 and 2000 infections such as chlamydia, gonorrhoea and syphilis increased by 107 per cent, 102 per cent and 145 per cent respectively (Health Protection Agency, 2001). In response, the Department of Health (2001) produced a national strategy for sexual health and HIV, with the aim of reducing transmission and prevalence rates of STIs and HIV, reducing unintended pregnancies and reducing the stigma associated with STIs and HIV.
One area highlighted in the strategy was the lack of good-quality service provision by specialist clinics due to their increasing workload. The strategy therefore proposed a more structured approach that would involve primary care services in collaboration with existing services to provide comprehensive sexual health care in a wider range of settings.
An important element in assessing and identifying an individual's risks in relation to STIs and/or HIV or other sexual problems is sexual history-taking. Sexual history is taken for a number of reasons:
- To ascertain individuals' risks of acquiring STIs or HIV by undertaking a risk assessment of their sexual behaviour;
- To ensure relevant investigations are undertaken;
- To elicit information that may be required for the process of notifying sexual partners;
- To assess sexual risk behaviour and make appropriate referrals to other specialist services;
- To identify the risk of unplanned pregnancy and the individual's contraceptive needs;
- To advocate and promote sexual health through education and information.
As with all other forms of information gathering, the practitioner needs good communication and listening skills as well as an ability to initiate discussion around an individual's sexuality and how it may be affecting their sexual health - for example whether they have any psychosexual problems or engage in high-risk behaviour. It is essential that practitioners are aware of and can identify the diversity of sexual relationships and lifestyles.
To ensure the assessment is comprehensive, the practitioner needs:
- A thorough knowledge of all aspects of STIs and HIV including transmission, signs and symptoms, incubation periods, sequelae of infection if left untreated and differential diagnoses;
- A knowledge of contraception and fertility issues;
- An awareness of the rationale for the questions that need to be asked;
- An ability to link signs and symptoms to differential diagnoses;
- A knowledge of appropriate diagnostic investigations and examinations that may be required.
A range of other factors must be considered when discussing sexual health, particularly in relation to the patient's perspective:
- Having to discuss intimate details of sexual practices and behaviour can cause some people great embarrassment or shame;
- It is vital to understand confidentiality requirements and what information may be disclosed and to whom;
- Practitioners' own assumptions about and attitudes to their patients' choice of sexual lifestyle;
- Cultural and language barriers;
- Past experiences such as sexual abuse or rape;
- Lack of understanding and awareness of the sexual health needs of those with learning difficulties and/or physical disabilities.
There are several principles involved in taking a sexual history. The consultation should take place in surroundings in which the practitioner and patient cannot be disturbed or overheard. It is important to emphasise the service's confidentiality arrangements to create an atmosphere of trust that will encourage the patient to discuss any concerns and anxieties.
The information gathered can facilitate and determine laboratory investigations, examination, follow-up and partner notification. The process of partner notification ensures sexual contacts of a patient diagnosed with an STI are informed, for example by a contact slip using a national code, which enables them to access a sexual health clinic of their choice (MedFASH, 2005).
Before starting the consultation it is useful to explain the nature and relevance of the questions that will be asked to ensure the patient feels comfortable and able to be open about their sexual lifestyle. The language used by both practitioner and patient is important in establishing rapport, particularly when discussing sexual behaviour and anatomy. It may be helpful to reflect the language used by the patient but this should only be done if it is acceptable to both practitioner and patient. To avoid misunderstandings, medical jargon and slang should be avoided.
When asking: 'When did you last have sex?' it is important to clarify what is meant by 'sex'. The word has many interpretations and does not only mean vaginal, anal or oral penetration. It is therefore useful to ask what type of sex this was - this allows the patient to define their sexual behaviour and gives the practitioner a clearer understanding of risk factors and high-risk behaviours for acquiring an STI or HIV, such as unprotected anal penetration with casual partners.
It is important to ascertain the gender of the partner/contact. Incorrect assumptions about sexuality will not only lead to inappropriate tests but will also undermine trust and rapport, resulting in the patient no longer being open about her or his lifestyle.
Many sexual health clinics use specific history-taking pro formas, which enable practitioners to make a comprehensive risk assessment and determine what further action is needed. The following is an example of a structured approach to sexual history-taking, and includes rationale(s) for typical questions asked in assessing sexual health needs. It consists of:
- Presenting complaint;
- Sexual behaviour (Box 1);
- HIV and hepatitis risk assessment.
While not all non-specialist areas will have a specific sexual health pro forma, it may be useful to adapt and integrate some questions into existing documentation for particular situations, such as managing vaginal discharge in a contraception clinic or HIV assessment and testing in the community.
After introduction to the patient it may be useful to start with: 'What's brought you here today?' or 'How can I help you today?' If the patient complains of symptoms, it is important to ascertain:
- Their duration and whether this is an acute or chronic presentation;
- If the symptoms have become worse or resolved from the initial episode;
- Whether there are other associated symptoms such as pruritis, dysuria, lower abdominal pain or testicular pain;
- Whether there are any systemic symptoms, such as flu-like illness, general malaise, rash, fever or myalgia;
- What triggers the symptoms - for example, pain on penetration or heat (scabies);
- If the patient has self-treated or been given any medication by a doctor;
- If the patient has experienced similar symptoms before and what the diagnosis was.
A sexual history should still be undertaken, even if the patient is asymptomatic. With chlamydia infection, up to 70 per cent of females and 50 per cent of males have no symptoms (DoH, 1998), and 10-30 per cent of females with untreated chlamydia will develop pelvic inflammatory disease (HPA, 2005).
HIV and hepatitis
The questions below mainly relate to risk assessment for HIV but can also be used in assessing for hepatitis B and C. They may also help to determine sexual behaviour risks and whether the patient requires further support or referral to specialist services:
- Have you ever been tested for HIV before?
- Have you ever injected drugs or shared needles? l Do any partners (current or past) inject drugs?
- Have any partners ever tested positive for HIV?
- Did you ever have a blood transfusion before 1985 in the UK or elsewhere?
- Have you donated blood (this may indicate if the patient has been tested for HIV and hepatitis B and C)?
- Have you ever had sex with men (male patients)?
- Is your partner bisexual (female patients)?
- Have you had unprotected sex with someone from a country that has a high prevalence of HIV?
- Have you any tattoos or body piercings?
The practitioner should also consider (by referring to current national and local guidelines) who should be offered hepatitis A and hepatitis B vaccinations.
The process and principles of sexual history-taking can be adapted to all health care settings and a range of situations. For example, taking cervical smears may create an opportunity to discuss chlamydia screening, while discussing a man's antihypertensive treatment could lead to discussion of issues and anxieties around erectile dysfunction.
Some health care professionals may not feel they have the skills to initiate discussions about sexual health and sexuality, due to embarrassment or lack of experience. Time restraints may be a factor for those in primary care. Several initiatives have been developed to provide training and education on attitudes and skills around sexual health, including a distance learning sexual health skills course (RCN, 2004). The British Association for Sexual Health and HIV (BASSH) has produced a foundation course that provides multidisciplinary training on the management and prevention of STIs called the STIF course (BASSH, 2005). These training tools can be used by all health care professionals who wish to develop professionally and personally on gaining more understanding around sexual health issues.
This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net
Each week Nursing Times publishes a guided learning article with reflection points to help you with your CPD. After reading the article you should be able to:
- Explain the process and principles of taking a sexual history;
- Understand why a sexual history is taken;
- Discuss the skills and knowledge required to take a sexual history;
- Recognise the importance of risk assessment;
- Understand the rationale behind questions asked in gathering information. Guided reflection
Use the following points to write a reflection for your PREP portfolio: - Write about where you work and your experience of taking a sexual history;
- Outline why you decided to reflect on this article for your CPD;
- Summarise a new piece of information you have learnt;
- Describe how this will impact on your future practice;
- Explain how you will follow up what you have learnt.