A Guide To Sexual History Taking With Men Who Have Sex With Men (MSM)
A. Getting Started: Introductory Statements and Questions
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Adults
"Now I am going to take a few minutes to ask you some direct questions about your sexual health. These questions are very personal, but it is important for me to know so I can help you be healthy. I ask these questions to all of my patients regardless of age or marital status and they are just as important as other questions about your physical and mental health. Like the rest of this visit, this information is strictly confidential."
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Teens
Care needs to be taken when introducing sensitive topics such as sexuality with teenagers. It is important to interview the teen alone and reinforce confidentiality. For teens, the sexual history can be incorporated into a broader risk assessment which addresses issues related to home, school, drug use, smoking, etc. Discussions should be appropriate for the teen's developmental level.
"Now I am going to take a few minutes to ask you some sensitive questions that are important for me to help you be healthy. Anything we discuss will be completely confidential. I won't discuss this with anyone, not even your parents, without your permission."
"Some of my patients your age have started having sex. Have you had sex?"
or
"What are you doing to protect yourself from AIDS, HIV, or other STDs?"
If you identify that the teen is sexually active, you will want to continue with a more complete sexual history.
B. The 4 "P"s: Partners, Sexual Practices, Past STDs, and Protection From STDs
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Partners
For sexual risk, it is important to determine the number and gender of a patient's sexual partners. One should make no assumptions of partner gender in the initial history taking. If multiple partners, explore for more specific risk factors, such as patterns of condom use and partner's risk factors, (i.e., other partners, injection drug use, history of STDs). If one partner, ask about length of the relationship and partner's risk, such as other partners and injection drug use.
"Do you have sex with men, women, or both?"
"In the past two months, how many people have you had sex with?"
"In the past twelve months, how many partners have you had?"
If the patient has sex with both men and women, repeat these questions for each specific gender.
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Sexual Practices
In addition to determining the gender and number of partners, it is also important to ask about sexual practices and condom use. Asking about sex practices will guide risk-reduction strategies and identify anatomical sites from which to collect specimens for STD testing.
"I am going to be more explicit about the kind of sex you may have been having over the last year so I understand your risks for STDs."
"Do you have vaginal sex, meaning penis in vagina sex?"
If answer is yes,
"Do you use condoms: never, sometimes, most of the time, or always for this kind of sex?"
"Do you have anal sex, meaning penis in rectum/anus sex?"
If answer is yes,
"Do you use condoms: never, sometimes, most of the time, or always for this kind of sex?"
"Do you have oral sex, meaning mouth on penis/anus/vagina?"
If condom use is inconsistent, then
"In what situations, or with whom, do you not use condoms?"
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Past History of STDs
A history of prior Gonorrhea or Chlamydia infections increases a person's risk of repeat infection. Recent past STDs indicate higher risk behavior. Retesting for Gonorrhea and Chlamydia is now recommended three months following a diagnosis of either infection in both men and women.
"What STDs have you had in the past, if any?"
"Have you ever had an STD, such as Chlamydia, Gonorrhea, Herpes or Warts?"
If answer is yes,
"Do you know what the infection was and when it was?"
"Have any of your partners had an STD?"
If answer is yes,
"Do you know what the infection was and when it was?"
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Protection from STDs
"What do you do to protect yourself from sexually transmitted diseases and HIV?"
With this open-ended question, you allow different avenues of discussion: condom use, monogamy, patient self-perception of risk, and perception of partner's risk. If you have determined that the patient has had one partner in the past 12 months and that partner has had no other partners, then infrequent or no condom use may not warrant risk-reduction counseling.
C. Additional Questions to Identify HIV and Hepatitis Risk
Immunization history for Hepatitis A and B can be noted at this point, as well as past HIV testing. Hepatitis A and B immunization is recommended.
"Have you ever gotten the Hepatitis B vaccine (all 3 doses)?"
"Have you ever gotten the Hepatitis A vaccine (2 doses)?"
"Have you ever been tested for HIV, the virus that causes AIDS?"
D. Finishing Up
By the end of this section of the interview, the patient may have come up with information or questions that he was not ready to discuss earlier.
"Is there anything else about your sexual practices that I need to know about to ensure you good health care?"
"Do you have any questions?"
At this point, review and reinforce positive, protective behaviors. After reinforcing positive behavior, it is appropriate to address specific concerns regarding higher risk practices. Your expression of concern can then lead to risk-reduction counseling or a counseling referral.
Adapted from the Chlamydia Care Quality Improvement Toolbox created by California Chlamydia Action Coalition. 2/2006