Sexual health is an important aspect of patient wellbeing, and is just as important as physical or mental health. It is therefore a key element for all advanced clinical practitioners (ACPs) to consider within their practice. Sexual health, according to the World Health Organization (WHO) (2022), ‘requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled’. Despite sexual health being such an important aspect of wellbeing, health professionals still find the topic challenging to address within a consultation (Dyer and das Nair, 2013).
Sexual ill health has an impact not only in a social context but also in terms of financial resources, with an increasing number of sexually transmitted infections (STIs) placing increasing stress on the health service. Iacobucci (2020) reported that, in the past decade in England, there has been a 249% increase in cases of gonorrhoea and a 165% increase in cases of syphilis. The incidence of STIs in England has risen from 425 933 in 2017 to 468 342 in 2019 (Mitchell et al, 2020). These numbers highlight the need for all ACPs, whether or not in specialist sexual health roles, to understand the principles of a sexual health consultation as they may have to support patients who present with a sexual health concern outside purely specialist clinics.
It is worth remembering that, although the impact of a sexual health condition will affect the presenting individual themselves, it will also have a direct impact on the person's partner(s) and children (born and unborn). The wider reaching impact is not always initially obvious, but it should be considered and discussed during consultation.
Key points before commencing a sexual health consultation
History taking and examination should always be undertaken with the patient's comfort in mind. While all consultation episodes should be undertaken in a sensitive and professional manner, this is particularly pertinent when these are related to sexual health. The use of a confidential and private environment is key when taking a sexual history, and requires significant consideration by the ACP prior to commencing questioning in this area (Brook et al, 2020).
For all consultations—and this is particularly pertinent to a sexual health consultation—the gender identity of the person presenting has to be considered and understood as part of the process. It is important for the ACP to be sensitive to the topic of gender identity when approaching a consultation.
Communication and body language
Presenting to a health professional with a sexual health concern can be both frightening and uncomfortable for many patients and reassurance should be offered, assuring that confidentiality and privacy will be maintained. While it is usually possible to maintain confidentiality, under some circumstances this may not be possible or may be unethical. Should such a situation occur, this should be made explicit to the patient. Prior to commencing history taking and examination, it is useful to explain to the patient that they may be asked personal, intimate and, potentially, embarrassing questions during the process, but also to explain that these are necessary for accurate diagnosis and that only pertinent questions will be posed. Hopefully, this can provide the patient with reassurance and prepare them for the necessary questioning.
All ACPs should be aware of how to maintain a non-judgemental approach to consultation and discussion in a sexual health context. The use of tools such as SOLER (Egan, 1986) are a useful aid when undertaking face-to-face consultations. The SOLER mnemonic stands for Sit squarely, Open posture, Lean forward, Eye contact and Relaxed body language. This tool offers a simple explanation of body language and posture; it can support communication and help build relationships because it aims to assist demonstrating interest in the patient. In the past few years, and especially during the pandemic, telephone and online consultations have become more widely adopted. However, this approach can present barriers to communication and the health professional will therefore need to rely on well-developed communication skills. For example, the ability to recognise non-verbal cues can be hindered when a consultation does not take place face to face, and this can be of particular concern when identifying issues that may require safeguarding. The drawback of remote consultations is the lack of non-verbal cues, which can make it more challenging for the health professional to recognise potential red flags.
Consent and chaperones
All examinations and consultations should ensure that consent is gained and documented, alongside consideration of the use of a chaperone or offering the patient the option of consulting with a same-sex clinician. A chaperone should be available and offered to all patients, regardless of age (Brook et al, 2020).
A 7 ‘P’ approach to questioning on sexual and reproductive health has been suggested as a useful prompt to consider key areas: Partners, Practices, Protection from STIs, Past history of STIs, Prevention of pregnancy, Permission (consent), Personal identity (gender identity) (Johnson, 2020). Although this has been recommended for use with adolescents or young people, the 7 Ps can be applied to a consultation with any individual, regardless of age.
Commencing the consultation
Introduce yourself and your role to the patient. Confirm their name and, if appropriate, which pronouns they use. It is important to be aware that transgender persons may suffer health disparities and may not be invited for appropriate routine screenings such as cervical smear tests. Open questioning can be used to initiate the consultation, however some direct questioning may be helpful and required as the consultation progresses. When approaching a sexual history consultation, it is important to consider the use of sexually explicit language or language that the patient—and the ACP—are both comfortable with. Recognising the need to stop or pause a consultation is also a key element for an ACP to consider by recognising the individual's body language or non-verbal cues, which may indicate anxiety or distress from the questioning and examination.
An initial step in the consultation is to observe how the patient presents, noting any obvious condition or behaviours that may be pertinent to the presenting complaint. This may also provide the ACP with an indicator as to whether the patient is uncomfortable or embarrassed about the situation and will allow the health professional to provide additional reassurance and help reduce their anxiety.
History of presenting complaint
Taking a thorough history will not only aid diagnosis, but will also identify risk factors and potential sources of infection or causes of ill health. The mnemonic SOCRATES, primarily used for pain assessment, has been adapted for a sexual health consultation (Table 1). Other questions that it is important to ask patients in a sexual health consultation are outlined in Table 2.
Table 1. SOCRATES, adapted for sexual health consultations*
| Site | In what area of the body is the presenting complaint? Are there multiple areas? |
| Onset | When were the symptoms/signs first noticed? |
| Characteristics | Can you describe the presenting complaint? Type of pain/discomfort |
| Radiation | Are the symptoms/pain moving into any other areas of the body? |
| Associated features | Is there any other symptoms apart from the primary? Nausea? Vomiting? Weight loss? Dizziness? Confusion? Lethargy? Discharge? Blood? Altered bladder/bowel habits? |
| Timing | When do the symptoms/pain present? Is there a pattern? Is it better/worse at day/night? |
| Exacerbating/relieving factors | Is there anything that offers relief from the pain/symptoms, or any thing that makes them worse? |
| Severity | If there is pain, what would the patient score it? What are the severity of other symptoms? What is their impact on activities of daily living (ADLs)? |
Table 2. Key questions to ask as part of a sexual health consultation
| Sexual intercourse |
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| Sexual health history |
|
| Other pertinent questions |
|
After taking the patient history, it is an opportune moment to offer the patient a summary of the information gathered so far. This will allow them the opportunity to correct anything that may have been misinterpreted or to add any further pertinent information. This pause will also allow the ACP time to offer the patient an explanation of the next stages of the consultation and examination, and to obtain consent to proceed.
Past medical history
Initially, open questions should be used to elicit the patient's past medical history, allowing the individual to provide any information they are able to recall. Once the patient has offered their past medical history it is worthwhile asking specific questions, such as regarding any hospital admissions: ‘Have you ever been seen in or admitted to hospital before?’
Asking about specific systems and conditions can be a useful trigger for patients to recall their medical history, for example: ‘Have you ever had any chest, lung or heart problems?’ and ‘Have you ever been diagnosed with a stroke/heart attack/asthma/diabetes?’ It can be useful to employ more widely recognised terminology, such as heart attack rather than myocardial infarction (MI), as some patients may not be aware of the terms.
Medication
Again, it is helpful to ask the patient whether they are on any medication and, if yes, the names and doses of what they are taking. If the ACP is able to retrieve a recent list of the patient's medications, this can be checked with them. However, it is important to mindful that many medications prescribed in clinics and through private health care will not be documented in a patient's NHS notes.
Hormonal therapies are regularly purchased online and a careful drug history should inquire about all over-the-counter, herbal, homeopathic, illicit, supplementary and alternative medications and therapies the patient may have been taking. It is worth asking specifically about inhalers and sprays because these are often overlooked by patients when discussing medications.
A contraceptive medication history is also important when obtaining a sexual health history: this includes oral contraceptives, coils, emergency contraception and spermicides.
Family history
While a family history may not immediately appear important within the context of a sexual history consultation, it would be remiss to exclude this. Strong family history of disease or ill health may not be linked to the presenting complaint, but it may require further consultation or investigation for preventive interventions or may offer clues to any unexpected symptoms that are uncovered during the systemic history taking.
Social history
Social history is a topic that can be uncomfortable for patients to discuss, so it should be addressed in a sensitive and non-judgemental fashion. Employment history should be gathered, and any high-risk occupations considered as a potential cause of presentation and clearly documented. Smoking and alcohol history are both vital parts of the exploration of social history and any changes in habit should be documented. Smoking history, described in pack years—which is a figure calculated by dividing the average number of cigarettes smoked per day by 20 and multiplying the result by the number of years smoked—for both smokers and ex-smokers should be obtained, and weekly alcohol unit intake should also be calculated. If the patient is abstinent, it is worth noting previous alcohol intake, if any, and any previous alcohol excess.
Current and past drug history is an important topic to cover during a consultation and should include any illicit, herbal, homeopathic and alternative drugs, medications or substances the patient may have taken. This should include anything taken orally, smoked, injected, inhaled/sniffed and applied topically. It is also critical to establish whether the patient is using any drugs that are used to facilitate sex, including psychoactive substances used in chemsex.
Systemic enquiry
The systemic enquiry allows for completeness of the history, ensuring that all body systems are reviewed. This step often uncovers symptoms or issues not previously mentioned because it investigates the body systems not immediately linked to the presenting complaint. It is important to undertake a systemic enquiry as part of a sexual health consultation because it allows any potentially related symptoms to be uncovered and ensures that any underlying issues can be addressed.
Cardiovascular
Chest pain, palpitations, syncope, oedema, intermittent claudication.
Respiratory
Shortness of breath, sputum, cough, wheeze, dyspnoea.
Gastrointestinal/genitourinary
Nausea, vomiting, urinary symptoms, haematuria, abdominal pain, diarrhoea, changes in bowel/bladder habit, menstruation-related issues/changes.
CNS [central nervous system]
Fevers, fits/faints/funny turns, mobility, dizziness.
Integumentary
Rashes, lesions, warts, skin discolouration, itch, hair loss.
HEENT [head/ears/eyes/nose/throat]
Headache, visual/auditory disturbances, mouth ulcers, swallowing difficulties, sore throat, coryzal symptoms.
Mental health
Impact of presenting complaint, usual mental health/ill health, concerns, ideas and expectations, support networks.
Summing up and advice
At the end of the history taking it may be useful to sum up the information gained and feed it back to the patient in a succinct manner. This allows the patient the opportunity to reflect on the information that they have provided, ensure that it has been interpreted accurately, and offer any further information that may have been omitted.
This also creates a natural break in the consultation and a point at which the ACP can pick up on anything communicated by the patient that may be of concern, or that requires further discussion to assist or promote the patient to be sexually healthy in the future.
Physical examination
The examination process should be explained to the patient and consent gained for this examination. The physical exam should focus on any areas of symptoms, but before proceeding the necessity to undertake it should be carefully considered: the preceding parts of the consultation, including past medical and social history, along with tests, may be sufficient to ensure appropriate management and remove the need for an intimate examination
Externally, the ACP needs to look for obvious lesions, rashes, ulcers, discolouration and signs of infection such as heat or swelling. The ACP should note any obvious pain or discomfort indicated during the exam. An abdominal exam is obligatory in any patient presenting with abdominal or pelvic pain, and any subtle signs of discomfort or tenderness should be carefully noted, with checks made for masses and swelling, including any swelling of the inguinal lymph nodes.
Genital examination
Depending on the history and systemic examination, a genital examination may be required.
Internal examination such as visualisation with a speculum for patients with a vagina/cervix and a genital and prostate examination for patients with a penis/prostate may be undertaken, but should be carried out only by those competent in the clinical skill to do so—and only if such an exam is indicated from the patient's history. Examination of lymph nodes and a review of the patient's general health can provide further clues and ensure that no other underlying conditions are missed (Herbert, 2018).
Referral to specialists
Knowing when to refer on to specialist clinicians and making referrals can be key to ensuring the patient receives appropriate and timely treatment. Having a good working knowledge of referral pathways is advantageous, as is knowledge of potential treatments and investigations the patient may require, enabling the ACP not only to gain informed consent for the referral, but also to alleviate concerns around the referral.
It is important for the ACP to be aware of the limitations of their own knowledge. Being open and honest with the patient regarding uncertainty and the need for a specialist referral or advice can help build trust within the therapeutic relationship.
Conclusion
This article has presented key points to consider when approaching a patient consultation focusing on sexual health. Although this is in no way a comprehensive format, it outlines a structured approach for a sexual health consultation that can be taken by ACPs, including the salient points to cover as part of a consultation and the importance of carefully reflecting on areas to broach as part of history taking. The article has highlighted the importance of recognising when to refer on to other specialties and the value of the ACP having a good working knowledge of other specialties. Last, but not least, it has emphasised the pertinence of ensuring clear and open communication with patients throughout the process.
KEY POINTS
- Prepare the patient for the questioning and physical exam and, regardless of age, consider offering the option of a chaperone or a same-sex clinician to ensure the patient feels as comfortable as possible
- Ask only the questions that are required or essential to the presentation, paying particular attention to the use of appropriate language
- Ensure the environment is appropriate for both the examination and the patient's comfort
- Privacy and assurance of confidentiality are of upmost importance
CPD reflective questions
- Think about both open and closed questions that you would use in a sexual health consultation
- Consider how to support a patient in your care and how you would support them within the consultation if they become distressed or anxious
- Think about what local services or departments are available for referral or specialist advice
- Consider your own feelings on how conducting a sexual health consultation may not be part of your own routine practice