Emergency physicians often feel that taking a sexual history in EDs is something medical school and specialty training have not prepared them very well for. This comes as no surprise as it differs significantly from ordinary medical history taking. Personal, religious beliefs, our own sexuality and upbringing will undoubtedly further influence the way we take a sexual history.
This is a consultation that is often difficult, filled with embarrassment for both the patient who has to disclose a very private part of their life and the doctor who might be faced with practices they might not have encountered before (either in their own personal or professional life).
Do not, however, forget that this is a unique opportunity that might not present again for the patient to disclose clinical information and for you to be able to initiate treatment against potentially life-changing illnesses.
It is therefore essential that you maximise the time you will spend with your patient. We know that EDs are fast-paced and time-constrained environments. Some sexual health clinics offer a pre-clinic questionnaire as some patients might feel more comfortable disclosing some information in writing, but this is unfortunately not something most EDs could pragmatically put into routine practice.
I have listed below some tips/pitfalls for the uninitiated in order to help taking sexual history:
1. Make your patient feel comfortable
This sounds obvious but patients often feel embarrassed and humiliated about having to disclose such a private part of their life. Remember that if they took the courage to book into an ED (often in the middle of the night or during a weekend period), they have gone through a period of reflection, fear and anxiety before seeking urgent medical help. Some may have been the victim of sexual assault.
Introduce yourself with a smile (this is probably the only time you will smile but I will mention the appropriateness of smiling further down), sit at the same level as your patient (not on a trolley above them which can give a sensation of domination), respect their choice of having someone with them should they wish to do so (it is often not the case).
Make sure you use a quiet room where doors can close and you will not be interrupted. It is not appropriate to take a sexual history behind curtains where everything could be potentially overheard by patients/relatives/staff in an adjacent cubicle.
2. Think about confidentiality
This ties in mostly with the point above but it is important to gain the confidence of your patient. You need to do this BEFORE you start asking sensitive questions most patients would often not discuss even with their spouse or partner. I usually use the line: “this consultation is strictly confidential and no information will be shared with anyone (not even your general practitioner or spouse) unless you want us to do so. The more information you give me about what worries you and what happened, the better I will be able to help you today”.
3. Think about your body language and non-verbal communication
Your body language influences the willingness of the patient to disclose sensitive information much more than you think. Do not cross your arms or legs, do not fiddle with your wedding ring, do not roll your eyes and most importantly… do not burst into laughter at any information the patient discloses about what happened the night before (even if you have only encountered such things on a DVD on a lonely night). You will instantly lose your patient’s confidence; they will not be forthcoming with crucial information any more and might even decide to end the consult. The smile you had when you introduced yourself a few minutes ago should be gone by now to show your patient you take all of his/her concerns seriously even if they are not real in terms of risk. After all, the risk is what the patient defines it as until the end of the consultation when you can reassure them and take a decision together.
Try not to interrupt your patient and nodding is usually a good way of showing your patient you are following them.
There are things you will not be able to control, like your own pectoral flush or blushing but after all, even emergency physicians are human (well, some of them are anyway).
4. Think about words and terms.
You must remain professional in your note-keeping but also remember that some patients will not be familiar with some very poetic greek or latin terms like fellatio or cunnilingus (I had to google one term myself to make sure I spelled it right). You might need to use more layman’s terms like “oral sex”, but be careful – these might need further clarification as “oral sex” for example may refer to “oro-vaginal” or “oro-anal” involving bodily fluids (potentially carriers of sexually transmitted diseases). Also remember that orgasm is not synonym of ejaculation: one is a state of mind which is completely harmless in terms of disease transmission and the second a physiological reaction involving bodily fluids; the two are not always linked.
When writing your medical notes, “translate” the terms the patient has used into medical terms.
Try to use open & closed questions to avoid misunderstandings – “did the mentioned oral intercourse end up in an ejaculation?” The answer to this question can only be “yes” or “no” and informs a decision on the appropriateness of starting HIV post-exposure prophylaxis. If you need to be sure of the facts (at some points you will) then use a closed question.
The appropriate use of silence is also important as it allows some patients to recollect their courage or thoughts about what happened during a period of their life they would often rather forget.
It is essential and perfectly acceptable to explore some unusual sexual practices you might not be familiar with to ascertain the risks taken. Again, not easy but try something along the lines “I would like to make sure I understand this particular point well in order to be able to make sure I can make the right decision for you”.
Also remember that even medical terminology has evolved significantly in the past years and you will come across terms like MSM (men who have sex with men) which is a sexual act as opposed to being gay/homosexual which is a sexual orientation. Similarly terms such as sex worker are better descriptors than more archaic terms like prostitute.
5. Make sure you take an alcohol and drug history
This involves medical and recreational drugs use as well. Do not assume on the basis of class, religion, age or another characteristic that your patient would not be using drugs (either legal or illegal) recreationally (Ed – remember this?). Again, it is not an easy part of the consultation and it is important to re-assure your patient that the police will not be informed of this. This is important information to assess the risk(s) taken.
Alcohol/drug use and risk-taking behaviour often go hand-in-hand (Ed – e.g. ChemSex parties) and the patient might have only partial recollection of events (if any!) which can result in difficult decision-making for the clinician. Also enquire about current medication and over the counter medicine that might interact with some medications you might decide to prescribe.
6. Make sure you take a medical history
After all, it ties in with the sexual history. Diabetes or depression can result in erectile dysfunction in men or previous pelvic surgery in prolapses in women which potentially have serious repercussions on your patients’ sexual life.
7. Take a social history
Remember that your patient might be in a long term relationship and is unaware of their current risk until a sexually transmitted infection is definitely ruled out. Your patient might therefore need to use barrier contraception or abstain from sexual activities with their regular or other sexual partners. In the UK, it is not your duty as an emergency physician to organise contact tracing at this stage and you should not break the patient’s confidentiality unless there was great danger to public health . I am sure this last sentence could generate lengthy ethical debates but maybe we could address this in a future blog…
8. Make sure you seek appropriate specialist help if unsure
This could be by seeking senior help in your ED, consulting local or national guidances or simply “phone a friend” in the form of the on call sexual health clinician. My personal experience is they do not mind being called in the middle of the night for advice. Remember that with every hour wasted the efficacy of post-exposure prophylaxis for HIV falls significantly and patients might miss the 72h window period when it can be started if they present to you days after the potential exposure.
9. Organise appropriate specialist follow-up
Most of the EDs in the UK will not organise diagnostic tests from ED but refer the patient urgently to specialist sexual health clinics where appropriate tests and follow-up will take place. As an emergency physician, you will however need sometimes to make a decision to initiate urgent treatment in the ED based on the patient history, presenting complaint and medical history. This could be initiating post-exposure prophylaxis for HIV, an accelerated course of hepatitis B vaccine (and immunoglobulin) and/or antibiotics for a urethritis following a definite risky sexual exposure.
In Virchester, we have a very active and fantastic sexual health clinic almost adjacent to our ED where patients can present without an appointment or EPs can refer patients directly ensuring timely follow-up. Click here to find UK STI clinics.
This might not be the case for you if you work in a rural setting so make sure you familiarise yourself about your local area of practice if you are new to the job.
10. Consider sexual assaults carefully
Your ED should have guidelines for how these patients are managed, but here your role is usually to identify any life threatening injuries and treat those. Many areas have access to regional Sexual Assault Referral Centres (SARC) – this one is local to Virchester and patients can access it via the police or by self referral if they do not want to involve the police. Our local centre will arrange emergency contraception and testing for sexually transmitted infections, but urgent treatment will still need to be given in ED. It is advisable to familiarise yourself with your local arrangements for these patients.
Do not attempt to collect forensic samples; for these to be admissible in court they need a chain of custody (sometimes called a chain of evidence) – you can read more here.
Finally, all I’ve said is really pretty basic with many of the points above being features of good generic history taking and that’s true, but it seems that we often struggle. So, please take time to think and share these points to make us all better clinicians. Hopefully the above few points are useful for emergency physicians colleagues, old and new. Personally, I learn something new with every single new consult…
@baombejp on Twitter
Further reading: Dropbox – Forensic Issues for the ED (UK) – includes definitions from the Sexual Offences Act 2003