Asking someone about their sexual life is rarely appropriate. Asking a complete stranger about their sexual life is pretty much never appropriate.
“So, are you sexually active at the moment?”
“…single or return ticket?”
As a doctor, however you’ll need to uncover the deepest secrets of someone’s funtimes if you’re to be successful in your quest to treat their symptoms or give them any advice in the field. To do this you must build a sufficiently professional rapport that they trust you enough to divulge their sexual history, without making them or yourself too uncomfortable.
“Could you show me on this doll…?” – not a good way to do it
To begin with, as always, make sure that you have the right patient, at the right time and in the right environment (a patient expecting a respiratory clinic is going to be rather surprised). A calm, quiet and private atmosphere is going to help, and it may be appropriate to have a chaperone present in the case of vulnerable or particularly uncomfortable patients. Then you can do what you always do with a history:
- start with open questions
- gradually focus on the pertinent issues
- close with a broad summary
- ask about concerns and expectations
“What brings you here today?” – nice open question to start off, allows the patient to lead, and gives you a chance to see what their preferred vocabulary is when it comes to genitals, sex and discharge.
“I sense a great disturbance in my glistening man-shaft” – unlikely
“Can you tell me a little more about the discharge/smell/bleeding?”
“How would you describe the pain?”
“What do you think has caused it?”
Then, as with all histories, you want to ensure you SOCRATES the symptoms, to clarify in your mind what might be causing them:
- Site
- Onset
- Character
- Radiation
- Associated symptoms
- Timing
- Exacerbating and relieving factors
- Severity
Once you have established what the main complaint is, there are a few specific symptoms to check for, and remember to SOCRATES each one:
- For the proud owner of a penis:
- Have you had any pain in the penis/willy/man-shaft? (whatever the patient has said, within reason)
- Have you had any itching?
- Any redness?
- Any skin changes?
- Have you noticed any discharge?
- Urinary symptoms:
- Any pain when urinating/when you pee?
- Any blood in the urine/pee?
- Are you needing to pee more often than usual?
- Have you noticed any swelling?
- For the proud owner of a vagina:
- Have you had any pain in the groin/genitals/vagina/down below?
- Have you had any abnormal discharge?
- What does it look like?
- Does it smell?
- Do you have any itching or redness?
- Urinary symptoms
- Any skin changes?
- any changes around your bottom/anus/around the back?
- Do you have pain during or after having sex/intercourse?
- How would you describe it?
- deep?
- near the surface?
- How would you describe it?
- Have you had any tummy pain?
- whereabouts?
- SOCRATES
- Menstrual history
- When was your last period?
- Are your periods usually regular?
- how long do you normally have bleeding for?
- have they been out of habit recently?
- Do you have pain during your period?
- Do you notice bleeding after having sex?
- And do you ever notice bleeding between periods?
- is this a change from normal for you?
- Gynaecological history
- Have you had any gynaecological problems in the past?
- Ever had any gynaecological treatment or surgery?
- When was your last smear test if you’ve had one?
- how were the results?
- have you ever had an abnormal smear?
- Obstetric history
- Is there any chance you might be pregnant at the moment?
- Do you use contraception?
- May I ask what it is that you use?
- Have you had any issues with contraception in the past?
After this for both sexes, you’ll need to check for Systemic Symptoms, suggestive of a more widespread issue. Questions may include:
- Have you had any soreness in your joints?
- In your eyes?
- Have you felt feverish?
- Any rashes on the body?
Now comes the fun bit. It’s probably a good idea to give them a bit of a warning, something like:
“I have to ask a few personal questions now if that’s alright…”
Is likely to receive a better response than
“Now then now then….. What have we been up to between the sheets….?”
In order, the questions I like to ask are:
- “Are you sexually active at the moment?”
- “When did you last have sex?”
- “Was that with a man or a women or both?”
- “What did it involve?”
- Penetrative sex?
- Oral, Vaginal, Anal?
- YOU NEED TO KNOW EXACTLY WHAT WENT WHERE, especially in Men who have Sex with Men (MSM)
- was it his mouth/yours?
- did you both receive anal sex?
- YOU NEED TO KNOW EXACTLY WHAT WENT WHERE, especially in Men who have Sex with Men (MSM)
- “Are/were they from the UK or overseas, if you know?”
- “Are they a regular sexual partner?”
- “Did you use contraception?”
- “What was it that you used?”
- if condom:
- “Did you use it for everything?”
- “Have you had any other partners in the last 3 months?”
- If so, repeat questions for other partners
Now you can both relax a bit, and settle into some questions about general previous medical history:
“Now I need to ask a little about your general health”
- “Have you had any sexually transmitted infections in the past?”
- “Have any of your sexual partners had one that you know of?”
- “Is there anything that you regularly see your GP/a doctor for?”
- “Have you been in hospital for anything in the past?”
As always, drug history next:
- “Do you take any regular medications?”
- “Have you taken any antibiotics recently?”
- “Do you have any allergies?”
- “Do you react to any medications?”
Next up, social history
- “Are you a smoker/Do you smoke?”
- “How much/many packs a day?”
- “Do you drink alcohol?”
- “How much in a week?”
- “Any other drugs; cocaine, heroin, cannabis?”
Last of all, HIV risk is very important to ascertain.
- “Have you ever had an HIV test?”
- “Have you ever injected drugs?”
- “Have you ever had sex with a man?” (if a man)
- “Have you ever been paid for sex?”
- “Have you ever had sex with someone from an area where HIV is very common?”
Hopefully by the end of this you won’t have missed anything, and you’ll know more about their sexual history than… well anyone really
unicyclemedic 