Taking a Sexual History in the ED

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A complete sexual history is important in the investigation of several emergency department (ED) presentations. This is often challenging for students, as it can feel intimidating and uncomfortable to breach this topic with patients. Also, the setting of the ED is not inherently conducive to conversations like these, given the lack of established patient-staff rapport and perceived lack of privacy and time. As such, an organized approach with attention to the environment and patient’s comfort can help students feel confident and patients feel more at ease.

When is a Sexual History Necessary?

It is important to take a sexual history for patients presenting with any of the following:

  • Pelvic or abdominal pain;
  • Genital lesions;
  • Vaginal bleeding, discharge, itchiness, or dyspareunia;
  • Testicular pain or swelling, urethral discharge;
  • STI concerns (based on either exposure history or presenting complaint);
  • Suspected sexual assault or abuse;
  • Sepsis or non-specific infectious symptoms. For example, consider a sexual history in anyone with a fever, malaise, weight loss, or rashes;
  • Swollen atraumatic joints (think gonococcal arthritis) or conjunctivitis (chlamydia).

Before Getting Started:

As mentioned, several factors make taking a sexual history in the emergency department challenging, including the lack of established patient-physician rapport and possible difficulties maintaining privacy.​1​ Preparation and planning prior to the encounter can help to address these limitations. Before beginning, take a moment to examine your own discomforts and inherent biases in order to ensure you are creating an environment safe for all patients.

In every patient encounter, ensure that you maintain professionalism and are non-judgmental throughout in order to help the patient feel more comfortable. Refrain from making any assumptions about the patient.  Be aware of your body language, facial expressions, and word choice. Start by informing the patient that you will be asking sensitive questions and explain their significance to the presenting complaint. You may offer them the option to opt out of answering if they feel uncomfortable, however explain to the patient that their answers help guide your clinical decision making.​2​ Avoid medical jargon and use language that the patient is familiar with while remaining professional. It may be helpful to practice doing this on your own first (before speaking with patients) to get more comfortable asking questions and using the terminology.

Emphasize the confidential nature of the information shared (with some exceptions, such as disclosure of child abuse) and make every effort to ensure the patient’s privacy. Do not discuss sensitive topics with patients or review with your staff in locations where the discussion can be overheard. If the patient presents with a friend or family member, ask to interview them alone if the patient is comfortable.

The 5 P’s:

Start with: “Do you currently engage in sexual activity?” and if the answer is yes, ask about the following:​2​

Partners: Ask about how many partners the patient has currently and has had recently (for example since the onset of the symptom), and the sex of the partners.

Practices: Ask about the type of sex (oral, anal, or vaginal). You can preface this by informing the patient that this is important to understand the risk of certain STIs.

Protection from STIs: Ask about what the patient is using for STI protection, for example, abstinence, monogamy, or condom use.

Past history of STIs: A history of prior STIs may place the patient at a higher risk for a subsequent infection. Ask about STI history of current and past partners. If they have been diagnosed with an STI previously, ask about course of treatment and whether they had a test of cure performed.

Prevention of pregnancy: Ask whether the patient or their partner is trying to conceive a child, and if not, what they are using to prevent pregnancy.​2​

The Specifics:

When zeroing in on the chief complaint, start with OPQRST: onset, provocation/palliation, quality, region and radiation, severity, and time course. Ask about the following symptoms (where appropriate), and if present, ask the corresponding questions. If absent, document as pertinent negatives.​3,4​

SymptomQuestions
Vaginal bleedingWhen does the bleeding occur: limited to menstruation, post-coitally, between menstruation?

What is the volume of bleeding: how often is the patient changing pads/tampons? If bleeding is heavy, is there any fatigue, shortness of breath, dizziness, and weakness? This provides information about the functional impact of the bleeding.
Vaginal dischargeNote: gonorrhea, chlamydia, and yeast infections often present with abnormal vaginal discharge.

Assess for a change in discharge from the patient’s own normal:
Any changes to volume of discharge?
Any change in the colour of discharge?
Any change to the consistency of discharge? A thick curd-like discharge suggests vulvovaginal candidiasis.
Any change in the smell of discharge? Malodourous discharge with a fishy odour suggests bacterial vaginosis.
Dyspareunia (pain with sexual intercourse)Is the pain superficial (external surface of genitalia, for example genital herpes) or deep (pain in pelvis, for example with gonorrheal or chlamydial infection)? Is the pain sharp or dull?
Genital pruritis  Can be indicative of candida, bacterial vaginosis, genital herpes, chlamydia, gonorrhea, vaginal atrophy, or lichen sclerosis Any presence of rashes or lesions?
Genital skin changesAny skin lesions, such as blistering or rashes? Are the lesions painful, itchy, or painless?
Abdominal/pelvic painAny abdominal pain? If yes, where? Is it unilateral or bilateral?
Testicular pain/swellingNote: testicular pain and swelling may be suggestive of epididymo-orchitis (secondary to gonorrhea or chlamydia). Is the pain or swelling bilateral or unilateral? Any colour changes?
Urethral dischargeWhat colour is the discharge (is it purulent)? Is there any blood?
DysuriaAny urinary symptoms? Pain with urination has a broad differential which includes infectious causes (sexually transmitted infections, urethritis, vaginitis) and non-infectious causes (trauma, obstruction, local irritation, certain medications, etc.).   
FeverAny fevers? Chills? May increase the suspicion of an infectious process.

Other Aspects of the History:

In patients who menstruate, ask when their last menstrual period was. This can help determine the possibility of pregnancy, or conception-related conditions like implantation bleeding or ectopic pregnancies. Ask about the typical length of bleeding as well as length of the entire cycle. Ask about any recent changes to the blood flow.  A sudden change in menstruation pattern can be indicative of an acute process.

In patients with a cervix, ask about previous cervical (Pap) testing and any previous abnormal tests, and further investigations that have been done.

For patients who are (or have been pregnant), ask about number of gestations, including living children and pregnancy terminations or miscarriages. Be cautious with terminology, and use words like “termination” or “miscarriage” as opposed to “abortion,” given the weight that this word may carry colloquially. Ask about any previous complications with pregnancies. For patients who are currently pregnant, ask about the presence or absence of any contractions, bleeding, fetal movements, and rupture of membranes.

Finally, as with any other history, don’t forget to ask about past medical history, past surgical history, any medications, allergies, relevant family history, and social history. 

Sexual histories represent one of several uncomfortable conversations learners face during their education. By appropriately setting the scene, starting with the 5Ps and then moving into specific symptoms, learners can take an organized approach to taking a sexual history in the ED. In response, patients will be able to sense comfort and confidence and it will put them at ease! 

References:

  1. 1.
    McKinzie J. Sexually Transmitted Diseases. In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Elsevier; 2018:1197-1208.
  2. 2.
    A Guide to Taking a Sexual history. Centre for Disease Control and Prevention. Accessed November 29, 2020. https://www.cdc.gov/std/treatment/sexualhistory.pdf
  3. 3.
    Sexual and Reproductive Health. World Health Organization. Accessed November 29, 2020. https://www.cdc.gov/std/treatment/sexualhistory.pdf
  4. 4.
    Birtles A, Potter L. Taking a Sexual History . Geeky Medics. Accessed November 29, 2020. https://geekymedics.com/sexual-history-taking/

This post was edited and uploaded by Megan Chu.

Reviewing with the Staff

Taking a sexual history can seem like a daunting task when you are on your clinical rotations – becoming comfortable with this is equally important for both your education and the care of your patients. Here are some pointers for when you review your patient with your staff:
· Organize your thoughts ahead of time. It will make your presentation smoother and ensure that no key information is left out. If you are flustered, take the time to get it right.
· Check your biases. Do not use any stigmatizing language in your presentation. Refer to patients with their appropriate pronouns and include any special information particular to the patient.
· If you didn’t ask about something – say so. Please do not gloss over or infer an answer to a question you didn’t ask. It’s ok to forget to ask something – this will now be a good learning point between you and your staff.
· Have an initial management plan in mind and communicate this. It’s ok if we go in a different direction – this is all part of the clerkship learning process. Coming up with and committing to a plan is a key step in your medical development; practice this as often as you can.

Dr. Kari Sampsel
Dr. Kari Sampsel is a staff Emergency Physician and Medical Director of the Sexual Assault and Partner Abuse Care Program at the Ottawa Hospital and an Assistant Professor at the University of Ottawa. She has been active in the fields of forensic medicine and medical education, with multiple international conference presentations, publications, and committee work. She has been honored with a number of national awards in recognition of her commitment to education and awareness. She has founded a consultancy company to assist organizations in policy development, staff training, investigation and prevention of sexual harassment and assault. She is an avid CrossFitter and believes that strength and advocacy are the way to a better world.
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Monika Bilic

Monika Bilic

Monika Bilic is a medical student at McMaster University. She has an interest in emergency medicine and medical education.
Monika Bilic

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