Levels of evidence (I-IV) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Confidentiality
General Medical Confidentiality
All National Health Service (NHS) employees are expected to adhere to the Caldicott Principles for confidentiality, and guidance from the General Medical Council stresses the importance of confidentiality. General medical confidentiality in the United Kingdom (UK) is a common law duty. The duty of confidentiality to the patient is absolute except in very specific circumstances, such as when it is in the patient's or public's interest. This might include child protection cases, or cases where another individual is placed at risk of an infection.
Some infections diagnosed in genitourinary (GU) medicine clinics (particularly viral hepatitis) require statutory notification irrespective of the site of diagnosis.
Venereal Diseases Acts
The particular vulnerability of patients attending a GU medicine clinic is reflected by the requirements for confidentiality within a GU medicine clinic, which are even more stringent than in other parts of the NHS. These are defined by statute in the Venereal Diseases Acts of 1917 and subsequent NHS regulations.
Patient notes in GU medicine clinics are kept separately from other hospital notes, and General Practitioners (GPs) are not routinely informed of a patient's attendance, unless the patient has been initially referred by letter.
If it is in the patient's interest for another health care worker to be informed, their consent to disclosure should be sought.
The Physical Environment for Sexual History-Taking
- A welcoming, comfortable, confidential physical environment is likely to encourage openness when discussing sensitive issues, such as sexual behaviour. To facilitate this, the following measures should be adopted.
- Services may find that clearly displaying literature that stresses confidentiality of the clinic and the non-judgemental nature of assessment improves the consultation.
- Clinic administration procedures (storage/visibility of clinic files and clinic lists, etc.) should be designed to ensure that confidentiality is maintained between patients. Clinics should decide on the most appropriate way of calling patients for consultations such as calling by first name, full name, forename, or number. Care should be taken to confirm that patient identification is correct.
- Consultations should take place in private settings and behind a sound-proofed closed door.
- Students and observers should be present only with the patient's consent, and the wishes of the patient should be respected if the presence of a student or observer is declined.
Recommendation: Sexual history-taking should take place in a confidential, private environment. Evidence Level IV, Grade of Recommendation C.
Recommendation: All clinics should have a confidentiality policy that should be displayed in the waiting area or otherwise made available to patients. Evidence Level IV, Grade of Recommendation C.
Management of Sexual Contacts
- The utmost care should be taken to preserve the patient's and sexual contacts' confidentiality during the consultation. This can be difficult in certain situations, for example, where a patient attends as a contact of an infection, but does not know the reason for their attendance.
- The index patient must not be identified. The clinician must not confirm the identity of the index, even if raised by the patient, or reveal any details about a contact's attendance (or non-attendance) or clinical condition.
Communication
Clinic Access and External Communication/Advertising
- Although many individuals who are referred to or refer themselves to sexual health/GU medicine clinics will expect to be asked sensitive questions regarding their sexual behaviour, this may not be the case for all patients.
- Clinic advertising, including the use of websites and clinic leaflets displayed in other settings outside the GU clinic (i.e., GP surgeries, contraceptive clinics, schools, colleges, etc.), should explain the role of the clinic and what should be expected during a consultation. This may improve the acceptability of asking questions which may otherwise be perceived as being intrusive.
Recommendation: Clinic literature/advertising leaflets should include sections regarding the need to take a sexual history. Evidence Level IV, Grade of Recommendation C
Communication Skills
- Good communication skills are required by all clinicians and may be important in improving health outcomes. On the initial contact with a patient, there are some particularly important aspects of communication skills that are required and may be particularly important in obtaining an accurate sexual history: These skills include the following components: initial greeting of the patient; maintaining eye contact and using appropriate body language; initiating a consultation with open questions followed by exploration of initial concerns and more closed questions as the consultation continues; awareness of the signs of anxiety and distress from the patient; recognizing non-verbal cues from the patient.
- Particular issues that require training for sexual history taking include addressing attitudinal issues to sexual behaviour, specific knowledge about the range of sexual practice and developing an understanding of the need to maintain confidentiality within consultations.
- Although there are well-recognized models of best practice in communication skills training, assessment of the quality of communication skills is complex. A variety of different mechanisms for assessing communication skills have been proposed including patient questionnaires, direct or video-recorded consultation with patients or simulated patients.
- Recommendation: Assessment of clinician communication skills should form part of the assessment of service quality. Evidence Level IV, Grade of Recommendation C
Communication Difficulties
Availability of sign language interpreters, foreign language interpreters and access to Language Line are all strategies that may need to be adopted.
- Recommendation: All sexual health clinics should have policies in place to address the needs of patients with whom there are communication problems, including patients whose first language is not English, deaf patients and patients with learning difficulties. Evidence Level IV, Grade of Recommendation C
Components of a Sexual History
The appropriate detail of the sexual history will vary between services but should allow:
- A careful assessment of symptoms to guide the examination and testing
- An exposure history to elucidate which sites need to be sampled and the sexually transmitted infections (STIs) to which the patient may be at risk
- An assessment of use of contraception and risk of pregnancy
- Assessment of other sexual health issues (also allowing a discussion of psychosexual problems)
- Assessing HIV, hepatitis B and C risk for both testing and prevention
- Assessment of risk behaviours, which will then facilitate health promotion activity including partner notification and sexual health promotion
- A summary of a suggested 'core sexual history' is in the table below
Table. Core Sexual History Components
| Symptoms/Reasons for Attendance |
- Last sexual intercourse (LSI), partner gender, sites of exposure, condom use
- Previous sexual partner details as for LSI
- Previous sexually transmitted infections (STIs)
- For women: last menses period (LMP), contraceptive and cytology history
- HIV risk history
- Hepatitis B and C risk assessment
- Establish mode of giving results
- Establish competency/child protection concerns (if age <16 years)
|
Reasons for Attendance
It is best to start the sexual history with less intrusive questions regarding presenting concerns and symptoms before asking more sensitive questions regarding sexual behaviour. The reason for attendance should be ascertained. After this has been elucidated, the clinician should ask direct questions regarding any associated GU symptoms. All clinicians will ask further questions regarding the duration and nature of any reported symptoms.
Symptom Review
It is uncertain whether a symptom review in patients not reporting symptoms is useful. However, many GU medicine clinicians ask about specific genital symptoms in case this reveals overlooked or ignored problems. Many clinicians would routinely ask women presenting to GU medicine clinics if they had the following symptoms:
- A change in vaginal discharge
- Vulval skin problems
- Lower abdominal pain
- Dysuria
- Changes in menstrual cycle or irregular bleeding
Many clinicians would routinely ask men presenting to GU medicine clinics if they had the following symptoms:
- Urethral discharge
- Dysuria
- Genital skin problems
- Peri-anal/anal symptoms (in gay men)
Sexual History
- The more detailed parts of the sexual history outlined below may be elucidated during the initial discussion with the patient. However, they will more often be ascertained while asking more 'closed' questions later in the consultation.
- Services primarily undertaking STI screening may undertake a brief core sexual history to establish whether someone is at any risk to STIs and take a more detailed history if the STI screen is positive.
- Using 'bridging' questions, which link general lifestyle questions to sexual history questions or 'universal' questions (questions which are explicitly asked of all patients), may also help when introducing sensitive questions. The need to ask important questions regarding risk taking (such as homosexual relationships and injecting drug use), which some patients may find offensive, should be clearly explained to all patients.
Last Sexual Intercourse (LSI)
All individuals should be asked:
- Gender of partner
Rationale: To identify gay/bisexual men in order to take rectal and pharyngeal samples, undertake hepatitis screening and vaccination and offer HIV testing and counselling.
- Type of sexual intercourse/sites of exposure (oral, vaginal, anal)
Rationale: To identify which sites need to be sampled and in those gay men reporting anal intercourse to offer HIV testing and risk reduction.
- Condom use/barrier contraception during sexual intercourse (and whether the condom was consistently used and remained intact)
Rationale: Facilitation of condom promotion and risk assessment.
- Relationship with partner (long-term partner – record duration of relationship, non-traceable casual partner, traceable casual partner, etc.) Evidence Level IV, Grade of Recommendation C
Rationale: To facilitate partner notification
- Problems or symptoms of partner
Rationale: To identify STI diagnosis, or symptoms suggestive of an STI, in partners
Previous Sexual Partner (Before Partner of LSI Last Partner Change)
All individuals should be asked:
Time Period of Sexual History
Other Components of History
Previous STIs
Recommendation: all individuals should be asked about a history of STIs. Evidence Level IV Grade of Recommendation C
Past Medical and Surgical History
Rationale: To identify conditions that may be associated with or influence the management of STIs.
Drug History and History of Allergies
Recommendations
Contraceptive and Reproductive Health History
Recommendation: All women should be asked the following questions:
Risk Assessment
Recommendation: All individuals should have the following questions asked:
- Current or past history of injecting history of injecting drug misuse; sharing of needles, syringes or drug preparation equipment ('works'). Evidence Level IV, Grade of Recommendation C
Rationale: To identify the need for hepatitis B, hepatitis C and HIV testing and hepatitis B vaccination.
- Whether they have ever had sex abroad, other than with a travelling partner; the nationality or country of birth of their sexual partners.
Rationale: To identify sexual partners at higher risk of STIs and identify the need to test for STIs that are significantly less common in the UK. Evidence Level IV, Grade of Recommendation C
- Whether they have ever had medical treatment abroad.
Rationale: To establish the need to test for nosocomial bloodborne virus acquisition.
- HIV testing history
Rationale: To determine whether HIV testing is necessary.
- All individuals at risk for Hepatitis B (including sex workers, gay men and intravenous drug users [IDUs]) should be asked for Hepatitis B vaccination history. Evidence Level IV, Grade of Recommendation C. Rationale: identification requires serological testing of hepatitis B and vaccination.
- Men and women may be asked whether they have ever exchanged money in return for sex. Evidence Level IV, Grade of Recommendation C
Rationale: to allow appropriate health promotion and hepatitis B testing and vaccination.
Under 16 Years of Age
Competency
Recommendation: All patients less than 16 years of age should have their competency to consent to history taking and examination assessed and this assessment should be documented in the clinical notes. Evidence Level IV, Grade of Recommendation C
Child Protection Concerns
Where there are any concerns regarding a child's safety, there should always be serious consideration given to liaison with the local Child Protection Team.
Answers to the following additional questions may flag up the need for further assessment and liaison with the local Child Protection team:
- Whether parents/carers are aware of their sexual activity
- Whether parents/carers are aware of their attendance at the clinic
- Whether they have ever had sex against their will
- Age of partner
- Vulnerability (e.g., self-harm, psychiatric illness, drug or alcohol misuse)
Where children under the age of 13 years report sexual activity, this should be discussed with a senior colleague and there is an expectation that this will be discussed in confidence, with the local child protection lead. Reporting to the children's social care and police may be indicated but is not mandatory.
Closing the Sexual History
Recommendation: After the sexual history is completed, the clinician should:
- Check with the patient that they have no other concerns that have not yet been discussed.
- Explain the need for and nature of a clinical examination and the clinical test sampling and other investigations.
- Explain the need for and offer a chaperone for the examination to all patients. If the chaperone is declined by the patient, this should be recorded. Evidence Level IV, Grade of Recommendation C
- The mode of communicating results to the patient should be clearly established.
Documentation
- Recommendation: Record keeping of a sexual history should be in keeping with the recommended national good standards of practice.
- Many clinicians and medical services now employ proformas (see Appendix of the original guideline document). It has been suggested that sexual health services may also benefit from employing proformas, which may:
- Assist this record keeping
- Make history taking more systematic
- Reduce the chance of omitting important pieces of information
- Facilitate audit
Definitions:
Levels of Evidence
Ia
- Evidence obtained from meta-analysis of randomised controlled trials
Ib
- Evidence obtained from at least one randomised controlled trial
IIa
- Evidence obtained from at least one well designed controlled study without randomisation
IIb
- Evidence obtained from at least one other type of well designed quasi-experimental study
III
- Evidence obtained from well designed non-experimental descriptive studies such as comparative studies, correlation studies, and case control studies
IV
- Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
Grading of Recommendations
A (Evidence Levels Ia, Ib)
- Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.
B (Evidence Levels IIa, IIb, III)
- Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation.
C (Evidence Level IV)
- Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities.
- Indicates absence of directly applicable studies of good quality.
