Whereas most patients attending GU medicine will expect to be asked questions about sex, this is by no means always the case in primary care, even though the patient may have presented with genital symptoms. GU medicine clinicians spend their days asking patients fairly intimate questions about sexual habits and lifestyle and therefore feel comfortable with the questions and the replies. Most GPs will only infrequently need to take a sexual history and a degree of uncertainty regarding which questions to ask and how best to ask them is inevitable. The purpose of this short chapter is to provide basic guidelines on how to approach the patient presenting with genital symptoms or who is concerned that they may have acquired an infection from a sexual partner.
An unmarried female patient presenting with vaginal discharge provides a useful example of one possible approach to sexual history taking.
The following are the important questions:
- How long has the discharge been present?
- Is there any malodor (? bacterial vaginosis)
- Is there any associated vulval irritation or soreness (? candidiasis)
- Is the discharge white (? candidiasis, bacterial vaginosis) or yellow (? trichomoniasis, cervicitis)
- Have there ever been any previous similar episodes? If so:
- What was the diagnosis?
- Which treatments have been used?
- Have any previous treatments helped?
- Have you experienced any pelvic pain (? endometritis/pelvic inflammatory disease (PID))
- Has there been any bleeding between periods? (endometritis)
- When was your last period?
- Has there been any discomfort or pain during sexual intercourse? (the terms "when making love" or "when having sex" are preferred by some clinicians; use whichever you think will be appropriate for the patient and with which you feel comfortable)
- When did you last have intercourse/have sex/make love?
- Was it your regular partner?
(1) If no:
- Was it with someone you know well or a fairly casual contact (? able to contact again)?
- Was it a male partner or a female partner?
- Was he or she from this country?
- Had they recently spent any time abroad?
- Have you had sex with any other partners in the past few months?
(2) If yes:
- Is this a male partner or a female partner?
- When did you last have sexual contact with someone other than your regular partner? (This may be more appropriate left to the end of the consultation.)
Direct eye-to-eye contact usually works best for the more intimate questions. The last question can be difficult as patients are usually embarrassed to admit an "extramarital" or casual affair, so you need to try to achieve a lack of surprise and concern whatever the reply.
- If a male partner, has he mentioned that he has symptoms? For example, a penile rash or any discomfort passing urine?
- What are you using for contraception? (consistent use of condoms provides good protection against Chlamydia and gonorrhea)
- Are you currently on any medication? (some antibiotics predispose to candidiasis. Fixed drug eruptions may present as fairly extensive areas of erythema or ulceration on the external genitalia.)
You will appreciate that a number of these questions are aimed specifically at determining the risk of sexually transmitted infection. They may not be relevant to the patient with clinically obvious vaginal "thrush" but should be considered in women with, for example, troublesome vaginal discharge unresponsive to treatment.
If a woman's last sexual contact was with another woman, it is worth enquiring when they last had sexual contact with a man. Women who are exclusively lesbian are unlikely to have chlamydial or gonococcal infection whereas bacterial vaginosis appears to be slightly more common in lesbian than in heterosexual women.
A similar line of questioning to the above is required for men attending with genital symptoms such as dysuria, urethral discharge, epididymal tenderness, or genital ulceration. You should directly inquire the following:
- When they last had sexual intercourse
- Whether it was with a "regular" or "casual" partner
- Whether it was with a male or female partner
- Whether there have been other sexual contacts in the previous few months.
With men who have sex with men (MSM), one should also obtain a little more detail about clinically relevant sexual practices. For example:
• Do you usually practice "safe-sex"? (e.g. body-rubbing, mutual masturbation)?
• When did you last have penetrative intercourse?
• When you have penetrative intercourse do you usually penetrate your partner (ano-insertive) or does he penetrate you (ano-receptive) or is there both?
- if predominantly ano-insertive, when were you last ano- receptive?
- if predominantly ano-receptive, when were you last ano- insertive?
- do you routinely/always use condoms?
- are you having any problems with condoms splitting or tearing? (extra strong condoms are readily available; certain lubricants can damage condom latex (see ‘Condoms', Chapter 12)
• When did you last have oral sex? (Some infections can be passed from the throat to the urethra, e.g. non-specific urethritis (NSU), gonorrhea. HIV may also be transmitted by oro-genital contact.)
• Were you active and/or receptive? (i.e. your penis into partner's mouth or vice versa).
Other sexual practices that may lead to the transmission of infection or clinical complications include the following:
- "Rimming" (oro-anal contact): intestinal pathogens, hepatitis A
- "Fisting" (hand insertion into rectum): damage to the anal sphincter, rectal tears.
The issue of HIV infection should be raised if the history suggests a possibility of potentially risky sexual practices. Recent studies suggest that a number of young homosexual men perceive HIV as a problem affecting the "older generation" and are reverting to unsafe sexual practices, in particular unprotected anal intercourse with casual partners.
Syphilis is also appearing once again in the UK with oral sex proving an important route of spread amongst men who have sex with men.