PCM: Taking a Sexual History

=Objectives= This is a hard subject. There's a lot of style questions, so you will encounter many different suggestions as you learn this.

Why is it important

 * sexuality is important to patients & their sense of self
 * broad range of health/illness effect/affect sexual function
 * sexual behavior <--> STIs
 * should be addressed as a central health concern--not something peripheral

Gonorrhea
It is fairly common for gonorrhea to cause no symptoms, especially in women. The incubation period-the time from exposure to the bacteria until symptoms develop-is usually 2 to 5 days, but sometimes symptoms may not develop for up to 30 days.

Gonorrhea may not cause symptoms until the infection has spread to other areas of the body.

In women, the early symptoms are sometimes so mild that they are mistaken for a bladder infection or vaginal infection. Symptoms may include:

* Painful or frequent urination. * Anal itching, pain, bleeding, or discharge. * Abnormal vaginal discharge. * Abnormal vaginal bleeding during or after sex or between periods. * Genital itching. * Irregular menstrual bleeding. * Lower abdominal pain. * Fever and general tiredness. * Swollen and painful glands at the opening of the vagina (Bartholin glands). * Painful sexual intercourse. * Sore throat (rare). * Pinkeye (conjunctivitis) (rare).

Symptoms in men

In men, symptoms are usually obvious enough that they will cause a man to seek medical treatment before complications occur. But some men have mild or no symptoms and can unknowingly transmit gonorrhea infections to their sex partners. Symptoms may include:

* Abnormal discharge from the penis (clear or milky at first, and then yellow, creamy, and excessive, sometimes blood-tinged). * Painful or frequent urination. * Anal itching, pain, bleeding, or discharge. * Sore throat (rare). * Pinkeye (conjunctivitis) (rare).

Symptoms of gonorrhea that has spread to sites other than the genitals (disseminated gonococcal infection) include:

* Rash. * Joint pain or arthritis. * Inflamed tendons.

Chlamydia
In women, the bacteria initially attack the cervix (opening to the uterus) and the urethra (urine canal). The few women with symptoms might have an abnormal vaginal discharge or a burning sensation when urinating. When the infection spreads from the cervix to the fallopian tubes, some women still have no signs or symptoms; others have lower abdominal pain, low back pain, nausea, fever, pain during intercourse, and bleeding between menstrual periods. Whenever the infection spreads past the cervix into the upper reproductive system, permanent and irreversible damage can occur.

Men with signs or symptoms might have a discharge from the penis and a burning sensation when urinating. Men might also have burning and itching around the opening of the penis or pain and swelling in the testicles, or both.

Pelvic Inflammatory Disease

 * If you have PID, you may have any of these symptoms:
 * Abdominal pain (especially lower abdominal pain) or tenderness
 * Back pain
 * Abnormal uterine bleeding
 * Unusual or heavy vaginal discharge
 * Painful urination
 * Painful sexual intercourse
 * Symptoms not related to the female reproductive organs include fever, nausea, and vomiting.
 * Your symptoms may be worse at the end of your menstrual period and during the first several days following a period.

Demonstrate effective questions to obtain an accurate sexual history.

 * If you are seeking information, you're unlikely to offend patients. Just ask.  Some physicians believe asking for permission or prefacing your question actually makes people more uncomfortable.
 * First question: Are you sexually active? If no, when last if ever?
 * "Do you have sex with a) men b) women or c) both? These are three different questions, so don't ask them as one.
 * 5 P's (see below)
 * Second question: Do you (or your partner) have any concerns about your sexual health or sexual function?

Demonstrate sensitivity to sexual orientations and sexual practices.

 * Gather information indirectly to break the ice. Ask about where they live, who their family is, who they get social support from, etc.
 * Use gender neutral words: partner
 * Preface sensitive questions as part of a routine. "I routinely ask about sexual partners because....", "Some people have problems with their sexual function....", "I need to ask some more specific questions so I can figure out...."
 * Body language: eye contact, sitting, don't react to shocking information. A routine helps relax your own body language.

Demonstrate use of appropriate language for taking a sexual history.

 * "Partner" - gender neutral
 * Practice, practice, practice
 * formal language (see mengel text), no vernacular

Adolescents

 * Establish the doctor's office as a safe place to ask questions
 * requires more indirect questions, make sure to preface questions
 * focus on social history, curiosity, relationship status, other indirect questions
 * don't try to use slang or vernacular (unless they've used it first...though this is not usually appropriate for professionalism reasons)
 * define and qualify "sexual activity", ie sexual contact, oral sex, vaginal sex, etc.
 * establish confidentiality & rules of reporting

Describe the 5 P's of the sexual history.

 * 1) number of Partners (current, past, and sex of partners: men, women, both).  "In the past two months how many people have you had sex with?".  "Do you have sex with men, women, or both?"
 * 2) sexual Practices: vaginal, anal, oral
 * 3) Past sexually transmitted diseases
 * 4) Protection from STDs
 * 5) Pregnancy history and plans.  "Are you trying to get pregnant?", "What are you doing to prevent a pregnancy?", "Do you use [condoms] everytime?"

=References=
 * The ABC's of taking a sexual history
 * A basic sexual history (University of Virginia SOM)