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Introduction to History Taking and Principles of Sexual Health R Jones, S Barton

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Introduction to History Taking and Principles of Sexual Health R Jones, S Barton 444 Postgrad Med J: first published as 10.1136/pgmj.2003.016873 on 5 August 2004. Downloaded from REVIEW Introduction to history taking and principles of sexual health R Jones, S Barton ............................................................................................................................... Postgrad Med J 2004;80:444–446. doi: 10.1136/pgmj.2003.016873 Sexual health has a profound influence over an individual’s In the last century, before the discovery of antibiotics, syphilis was an untreatable condition physical and psychological wellbeing. There is an producing many visible manifestations leading to increasing need to develop effective strategies to reduce a similar stigmatisation as seen in HIV today. It the incidence of sexually transmitted infections (STIs) is self evident that HIV is just one of many conditions causing silent pathology followed by globally. Many STIs are asymptomatic and yet, highly visible clinical symptoms and signs. However, infectious. The sequelae of such infections may be ectopic pregnancy, hepatic failure, invasive cer- catastrophic and hence, an integrated multidisciplinary vical carcinoma, and pelvic sepsis as a sequela of termination of pregnancy cause mortality and and preventative approach to the control of STIs is clearly morbidity world wide, yet often fail to attract as necessary. Sexual history taking holds the key to the much media attention or become the focus of practice of sexual health medicine. It provides the basis for public health initiatives (box 1). treatment, prevention, education, and sexual health CONTROL OF STI promotion. In light of the above, a more integrated multi- ........................................................................... disciplinary and preventative approach to the control of STIs is clearly indicated. This has been embodied within the concept ‘‘sexual health’’. exual health has a profound influence over The government has produced an ‘‘HIV and an individual’s physical and psychological sexual health strategy’’,1 which advocates effec- Swellbeing. As we move further in to the 21st tive treatment of symptomatic conditions, and century, the global ramifications of the HIV improvement in knowledge and awareness of pandemic are evident both in social and eco- STIs among the public and health professionals. nomic terms and serve to highlight the impera- It hopes to reduce the transmission and pre- tive need for sexual health promotion in order to valence of HIV and STIs, even when undiag- reduce the burden of sexually transmitted dis- nosed, lower unintended pregnancy rates, eases. The UK, like other developed countries, improve health and social care for those living has now begun to recognise the crisis in the with HIV, and reduce the stigma associated with provision of sexual services for those requesting STIs. It emphasises the need to improve the http://pmj.bmj.com/ screening and treatment. The recognition of the multidisciplinary and cross specialty collabora- synergistic effect which ulcerative and inflam- tion in detection and management of STIs—for matory sexually transmitted infections exert on example, screening for STIs in women attending the transmission of HIV have, in the absence of for termination of pregnancy, as well as offering an effective anti-HIV vaccine, led to the increas- family planning advice to women attending with ing need to develop effective strategies to reduce STIs. Improving access to services by tailoring the incidence of sexually transmitted infections clinic hours, facilities, and approaches to cater (STIs) in both developed and developing coun- for the public’s needs will increase the number of on September 30, 2021 by guest. Protected copyright. tries. These infections have constituted a global asymptomatic individuals who utilise the service health problem for considerably longer than the for a check up—for example, walk-in clinics for AIDS epidemic and their prevalence continues to post-school visits have been designed to increase rise. uptake in the teenage population. Check ups Health strategies focusing on STIs have pre- should include, with consent, screening for a viously concentrated on improving treatment, whole range of local and systemic infections, as follow up, and contact tracing of those diagnosed well as providing advice, education, and infor- See end of article for mation with the emphasis on health promotion. authors’ affiliations with a STI. Treatment decisions are often ....................... difficult as exemplified by the therapeutic inter- Where conditions—symptomatic or asympto- ventions available for human papilloma virus. matic—are diagnosed, it is vital that appropriate Correspondence to: Specific strains of this virus have been shown to treatment, follow up, and contact tracing are Dr R Jones, Department of performed. Genito-urinary Medicine, cause genital warts and treatment modalities are St Stephen’s Centre, varied—cryotherapy, toxins, and immune mod- The five principles for improvements in sexual Chelsea and Westminster ulator agents. But, as with the infections HIV health care can be summarised as follows: Hospital, 369 Fulham Road, London SW10 9TH, and hepatitis C, there are many conditions that (1) Improved access and awareness. are sexually transmitted which do not cause UK; rachaeljones30@ (2) Improved diagnostic techniques. hotmail.com symptoms yet are infectious, either continuously or intermittently in their natural history. The (3) Improved therapies. Submitted morbidity and mortality associated with HIV/ (4) Improved follow up and contact tracing. 7 November 2003 Accepted 22 January 2004 AIDS exemplify the severity of the sequelae of (5) Availability of the above to a wider section of ....................... such an infection. the population. www.postgradmedj.com History taking and principles of sexual health 445 Postgrad Med J: first published as 10.1136/pgmj.2003.016873 on 5 August 2004. Downloaded from Box 1: Examples of sexually acquired conditions Box 3: Sexual history taking: an example of a which may be asymptomatic or subclinical structured approach during their natural history, but cause significant morbidity and/or mortality (1) When did you last have sexual intercourse? (2) With a man or a woman? N R R HIV infection immunosuppression AIDS. (3) Were they a casual or regular partner? N Hepatitis B infection R chronic hepatitis R hepatoma. (4) Where were they from? N Hepatitis C infection R cirrhosis R hepatocellular (5) In which country did you have sex? cancer. (6) What kind of sex did you engage in? N Sperm R unwanted pregnancy R termination R sepsis. (7) For each type—for example, oral/vaginal/anal—did ? N Oncogenic human papilloma virus cervical infection R you use a condom (For heterosexual sex: was any ? cervical intraepithelial neoplasia R cervical cancer. contraception used Relate to risk of pregnancy when inquiring about last menstrual period in gynaecology N Chlamydia trachomatis R pelvic inflammatory disease history). R ectopic pregnancy/infertility. (8) Does your partner have any symptoms? N Treponema pallidum R latency R tertiary syphilis. (9) Have you had any other partners in the last six weeks? If so, return to question 2. Offer questions which may lead to other problem identification. Finally, sexual health involves more than merely educating (10) Did you have pain during or after intercourse? and informing patients to change their ideas about the (11) Have you ever had any previous STIs (may require prevention and treatment of STIs. It is vital that medical information or counselling)? professionals of any specialty should not see sexual matters as being purely in the realm of the genitourinary medicine (12) Have you ever had a sexual health check up before clinics, dermatovenereologists, gynaecologists, or urologists. (explain and offer)? This matter has been discussed extensively as detailed in the (13) Have you ever had an HIV/hepatitis/syphilis test British Medical Journal editorial by Stedman and Elstin.2 It is before (explain and offer, pre-test counsel if appro- most likely that a range of approaches with a common goal priate)? will be individually tailored to the needs of different local (14) Have you been vaccinated against hepatitis A/B or populations and the resources available. Primary care and have you ever had hepatitis (assess risk and offer if accident and emergency physicians, in conjunction with appropriate)? those working in the above specialties, need to work in combination, utilising their expertise to improve the sexual health of the nation. SEXUAL HISTORY TAKING It is important to understand why certain questions should The most important aspect of taking a sexual history lies in be asked during a consultation. Often, it is useful to pre-empt http://pmj.bmj.com/ the concept that the patient needs to be reassured that his/ the patient’s discomfort by initially informing them that you her privacy and confidentiality are paramount (box 2). It is are about to ask very personal, and often embarrassing, essential to ensure that the conversation cannot be overheard questions. The early questions should be used to determine or interrupted. Only experience and skill in taking a sexual a person’s sexuality, thus exploring the patient’s risk of history can sympathetically encourage patients to reveal the STI acquisition, appropriate risk reduction information, and intimate details of their private life that are necessary to offering vaccination for hepatitis A/B if appropriate. It is determine the choice of
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