Sexual History Taking in Clinical Settings: A Narrative Review

The Effect of Using a Standardized Questionnaire on Sexual History Documentation and Testing to Diagnose Gonorrhea and Chlamydia Among Men Who Have Sex With Men With Human Immunodeficiency Virus

BACKGROUND

Most Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) infections in men who have sex with men (MSM) are diagnosed at extragenital sites. However, testing at these sites is often lacking. The purpose of this study was to determine if a standardized questionnaire administered by physicians and clinical assistants improves documentation of sex activity and increases extragenital testing and diagnoses of GC and CT among MSM.

METHODS

A standardized sexual history questionnaire was implemented on 11/1/2022. Electronic medical records of 664 MSM with human immunodeficiency virus, including 1064 encounters, were reviewed to compare preimplementation and postimplementation sexual history documentation, adequacy of documentation, extragenital GC and CT testing, and GC and CT diagnoses. Analysis included χ 2 and exact tests and logistic regression adjusting for physician cluster effects.

RESULTS

The standardized questionnaire was used by 53.7% of physicians and 85.9% of coordinators. Documentation of whether sexual activity occurred increased from 79.3% (95% confidence interval [CI], 0.758-0.828) in the preintervention pre-COVID-19 period to 95.2% (95% CI, 0.925-0.970) in the postintervention period with an adjusted odds ratio of 4.7 (95% CI, 2.7-8.8). Specific questions about anal and oral sex increased from 42.0% to 88.1% ( P < 0.001) and 23.7% to 88.7% ( P < 0.001), respectively. Anal and pharyngeal testing increased from 14.4% to 20.2% ( P = 0.040) and 17.2% to 23.3% ( P = 0.045), respectively.

CONCLUSIONS

This study demonstrates that using a standardized questionnaire during clinical encounters can improve documentation of sexual activity and testing for GC and CT at extragenital sites.

The Importance of Sexual History-Taking Within Surgery

ABSTRACT

Sexual and reproductive health is an essential part of comprehensive medical care. As the field of medicine becomes more specialized and siloed and the diagnostic workup in surgery more advanced, the risk of anchoring diagnoses and partitioning of care increases. Thus, the fundamentals of a complete patient history and review of each body system remain critical in ensuring that surgeons establish a broad differential diagnosis; provide comprehensive, well-rounded care to patients; and create opportunities for patient counseling and interventions. The article by Coleman and colleagues reports on an intervention that did not result in trainees being more likely to take a sexual history; however, the intervention group did ask significantly more questions regarding sexual health than the comparison group when they did take a sexual history. They highlight that there is a persistent gap in sexual history-taking, and that this results in potential misdiagnoses as well as missed opportunities to counsel patients about sexual and reproductive health. Clinicians have a responsibility to recognize factors that increase risk for their patients and provide appropriate counseling, which they cannot do if they are not asking all the necessary questions, even the difficult ones.

Sexual health in patient care: shortcomings in medical training and experienced barriers in sexual history taking

BACKGROUND

Sexual health is recognized as a fundamental component of well-being, with implications for individuals, communities, and healthcare practices. This study explores medical residents' perspectives on training in sexual history taking, emphasizing its importance and the challenges faced at the onset of their clinical practice.

METHODS

A survey was conducted among 167 medical residents at the largest medical school in Belgium and their training curriculum was analysed. The participants completed an online questionnaire addressing aspects of sexual history training, skills, knowledge, attitudes, and factors influencing sexual history taking.

RESULTS

The survey revealed several shortcomings in the medical training in sexual history taking. Dissatisfaction is expressed regarding the adequacy of provided training, with a prominent barrier being the lack of skills and knowledge necessary for effective sexual history taking. Discomfort, experienced by physicians and their patients, emerges as a critical factor affecting the initiation and quality of sexual history discussions. Other challenges include biases related to religion, ethnicity, age, and gender, while practical factors, such as time constraints and language barriers, underscore the multitude of obstacles in comprehensive sexual history assessments.

CONCLUSION

This study highlights the opportunities for improved training in sexual history taking in medical education, contributing to more inclusive and effective sexual history taking practices. Recommendations are made, including targeted interventions to improve skills, knowledge and attitude of the students.

Don't Overlook Syphilis: An Atypical Rash in a Woman With Neurologic, Ocular, and Otic Involvement

The manifestations of syphilis, a sexually transmitted infection caused by Treponema pallidum, can be divided into primary, secondary, or tertiary stages. In addition, syphilis can cause a latent infection with no clinical manifestations and be diagnosed solely by serologic testing. Secondary syphilis is especially known for causing a rash and diverse clinical manifestation which can make its diagnosis challenging-particularly in patients whose medical and sexual histories do not align with the classical epidemiologic and textbook description of secondary syphilis. We present a case of a 20-year-old immunocompetent heterosexual woman who presented with a rash atypical for secondary syphilis and accompanied by neurologic, ocular, and otic manifestations. This case highlights the importance of considering syphilis in the differential diagnosis of sexually active patients with a rash, even when their clinical presentations do not align with the textbook description of a syphilitic rash. Health care providers must remain vigilant for the diagnosis of syphilis in diverse clinical contexts, as early recognition and treatment are vital to prevent further syphilitic complications and transmission in military and civilian populations. Timely identification and intervention are crucial for both patient care and public health.

Relationships Among Determinants of Health, Cancer Screening Participation, and Sexual Minority Identity: A Systematic Review

Purpose: To address cancer screening disparities and reduce cancer risk among sexual minority (SM) groups, this review identifies individual, interpersonal, and community/societal determinants of cancer screening (non)participation among differing SM identities. Methods: Seven scientific databases were searched. Inclusion criteria were as follows: (1) used quantitative methods; (2) English language; (3) cancer screening focus; and (4) at least one SM group identified. Articles were excluded if: (1) analysis was not disaggregated by SM identity (n = 29) and (2) quantitative analysis excluded determinants of cancer screening (n = 19). The Sexual and Gender Minority Health Disparities Research Framework guided literature synthesis. Results: Twelve studies addressed cervical (n = 4), breast (n = 3), breast/cervical (n = 3), or multiple cancers (n = 2). Other cancers were excluded due to inclusion/exclusion criteria. The total sample was 20,622 (mean 1525), including lesbian (n = 13,409), bisexual (n = 4442), gay (n = 1386), mostly heterosexual (n = 1302), and queer (n = 83) identities. Studies analyzing individual-level determinants (n = 8) found that socioeconomic status affected cervical, but not breast, cancer screening among lesbian and bisexual participants (n = 2). At the interpersonal level (n = 7), provider-patient relationship was a determinant of cervical cancer screening among lesbian participants (n = 4); a relationship not studied for other groups. Studies analyzing community/societal determinants (n = 5) found that rurality potentially affected cervical cancer screening among lesbian, but not bisexual people (n = 3). Conclusions: This review identified socioeconomic status, provider-patient relationship, and rurality as determinants affecting cancer screening among SM people. While literature addresses diverse SM groups, inclusion/exclusion criteria identified studies addressing cisgender women. Addressing disparities in the identified determinants of cervical cancer screening may improve participation among SM women. Further research is needed to understand determinants of cancer screening unique to other SM groups.

Psychiatrists' Experiences, Training Needs, and Preferences Regarding Prescription and Management of HIV Pre-exposure Prophylaxis (PrEP) Within Psychiatric Care

Background

People living with mental illness (PLWMI) experience a disproportionate prevalence and incidence of HIV. Preventing HIV among PLWMI is a priority for multiple domestic public health agencies. As key clinicians for this group, psychiatrists may have an important role to play in increasing PrEP use among PLWMI.

Methods

A national survey of psychiatrists (N = 880) about integrating PrEP prescription into psychiatric practice was conducted between November 2022-October 2023. Specifically, we inquired about experiences with PrEP prescription, patient request for PrEP, and interest in prescribing PrEP. We also inquired about barriers to PrEP prescription in psychiatry and preferred models for implementing PrEP prescription in psychiatry.

Results

We found that 19.3% of psychiatrists had received a request for PrEP from a patient, 17.3% had prescribed, and 53.9% were interested in prescribing. The greatest percentage of psychiatrists who prescribed PrEP were practicing primarily in inpatient psychiatry (28.8%). Practicing in one of the federal Ending the HIV Epidemic (EHE) priority jurisdictions (aOR = 2.08 [1.23-3.54], p = 0.003) and greater self-confidence in PrEP-related tasks (aOR = 2.10 [1.67-2.65], p < 0.001) were associated with higher likelihood of PrEP prescription. Limited knowledge of PrEP was the barrier endorsed by the greatest percentage of psychiatrists (76.3%). Most preferred a hypothetical model in which a psychiatrist prescribed an initial course of PrEP with prompt primary care or infectious disease follow-up (63.1%).

Conclusion

Most psychiatrists were interested in prescribing PrEP. Training is needed to enable PrEP implementation in psychiatric practice including development of collaborative practice models to engage psychiatrists across a diversity of settings.

Reprint of: Impact of an HIV pre-exposure prophylaxis dashboard on veteran PrEP enrollment

BACKGROUND

Pre-exposure prophylaxis (PrEP) is highly effective at reducing the risk of human immunodeficiency virus (HIV) acquisition in at-risk individuals; however, it is largely underutilized. The Veterans Health Administration has created an HIV PrEP dashboard to identify at-risk veterans in attempt to increase PrEP enrollment.

OBJECTIVE

This study aimed to determine whether the use of an HIV PrEP dashboard would prove effective at increasing PrEP enrollment at a single facility.

METHODS

This was a single-center quality improvement project. Three pharmacists used the HIV PrEP dashboard and retrospective chart review to identify eligible patients for PrEP. A multimodal process of contacting patients was conducted. The primary objective was to evaluate the number of patients who enrolled in PrEP during the study period. Secondary objectives included evaluating the ability of the HIV PrEP dashboard to identify eligible patients, identify effective strategies to target PrEP enrollment, and compare those patients who accepted with those who declined PrEP to evaluate barriers to enrollment.

RESULTS

Of the 94 patients reviewed, 26 patients (27.7%) were found eligible for PrEP. Of the eligible patients, 3 patients (11.5%) were enrolled, and 7 patients (26.9%) declined PrEP. The others were lost to follow-up (9 of 26, 34.6%), had no action taken on a chart note to provider (6 of 26, 23.1%), or did not have a primary care provider assigned at the local facility (1 of 26, 3.9%). The 3 patients who were successfully enrolled in PrEP were all contacted and prescribed PrEP through the infectious diseases (ID) clinic. There were no statistically significant differences between the cohorts of patients who accepted and declined PrEP.

CONCLUSIONS

The use of an HIV PrEP dashboard aided in identifying eligible patients for PrEP. Enrollment through the ID clinic was the most successful modality. Further research is needed to characterize barriers to PrEP uptake and to develop strategies to increase prescribing from non-ID providers.

Clinical Updates in Sexually Transmitted Infections, 2024

Sexually transmitted infections (STIs) continue to increase in the United States with more than 2.5 million cases of gonorrhea, chlamydia, and syphilis reported to the Centers for Disease Control and Prevention in 2022. Untreated STIs in women can lead to adverse outcomes, including pelvic inflammatory disease, infertility, chronic pelvic pain, and pregnancy complications such as ectopic pregnancy, early pregnancy loss, stillbirth, and neonatal transmission. STI-related guidelines can be complex and are frequently updated, making it challenging to stay informed on current guidance. This article provides high-yield updates to support clinicians managing STIs by highlighting changes in screening, diagnosis, and treatment. One important topic includes new guidance on syphilis screening, including a clarified description of high community rates of syphilis based on Healthy People 2030 goals, defined as a case rate of primary or secondary syphilis > 4.6 per 100,000. Reproductive aged persons living in counties above this threshold should be offered syphilis screening. Additionally, American College of Obstetricians & Gynecologists now recommends syphilis screening three times during pregnancy regardless of risk-at the first prenatal visit, during the third trimester, and at delivery. In addition, new guidance to support consideration for extragenital screening for gonorrhea and chlamydia in women at sites such as the anus and pharynx is discussed. Other topics include the most recent chlamydia, gonorrhea, trichomoniasis, and pelvic inflammatory disease treatment recommendations; screening and treatment guidance for Mycoplasma genitalium; genital herpes screening indications and current diagnostic challenges; and the diagnosis and management of mpox in women and during pregnancy.

Pilot Test of A Gender-conscious Sexual Health Intake Questionnaire: Increasing Inclusivity and Mitigating Bias in Sexual History Taking

Background

Sexual health is critical to overall health, yet sexual history taking is challenging. LGBTQ+ patients face additional barriers due to cis/heteronormativity from the medical system. We aimed to develop and pilot test a novel sexual history questionnaire called the Sexual Health Intake (SHI) form for patients of diverse genders and sexualities.

Methods

The SHI comprises four pictogram-based questions about sexual contact at the mouth, anus, vaginal canal, and penis. We enrolled 100 sexually active, English-speaking adults from a gender-affirming surgery clinic and urology clinic from November 2022 to April 2023. All surveys were completed in the office. Patients also answered five feedback questions and 15 questions from the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction (PROMIS-SexFS) survey as a validated comparator.

Results

One hundred patients aged 19-86 years representing an array of racial/ethnic groups, gender identities, and sexuality completed the study. Forms of sexual contact varied widely and included all possible combinations asked by the SHI. Feedback questions were answered favorably in domains of clinical utility, inclusiveness of identity and anatomy, and comprehensiveness of forms of sexual behavior. The SHI captured more positive responses than PROMIS-SexFS in corresponding questions about specific types of sexual activity. The SHI also asks about forms of sexual contact that are not addressed by PROMIS-SexFS, such as penis-to-clitoris.

Conclusions

SHI is an inclusive, patient-directed tool to aid sexual history taking without cisnormative or heteronormative biases. The form was well received by a diverse group of participants and can be considered for use in the clinical setting.

Taking a Sexual History: Best Practices

Recognizing the holistic definitions of sexual health, health-care providers must approach sexual health history taking with sensitivity, inclusivity, and a trauma-informed perspective. Many versions of what a sexual history should look like exist but certain principles are commonly found. Education of health-care providers on sexual history taking can involve reviewing the components of the sexual history but should also include the importance of using nonstigmatizing language, having a patient-centered approach, and practicing trauma-informed and culturally sensitive care.

Impact of an HIV pre-exposure prophylaxis dashboard on veteran PrEP enrollment

BACKGROUND

Pre-exposure prophylaxis (PrEP) is highly effective at reducing the risk of human immunodeficiency virus (HIV) acquisition in at-risk individuals; however, it is largely underutilized. The Veterans Health Administration has created an HIV PrEP dashboard to identify at-risk veterans in attempt to increase PrEP enrollment.

OBJECTIVE

This study aimed to determine whether the use of an HIV PrEP dashboard would prove effective at increasing PrEP enrollment at a single facility.

METHODS

This was a single-center quality improvement project. Three pharmacists used the HIV PrEP dashboard and retrospective chart review to identify eligible patients for PrEP. A multimodal process of contacting patients was conducted. The primary objective was to evaluate the number of patients who enrolled in PrEP during the study period. Secondary objectives included evaluating the ability of the HIV PrEP dashboard to identify eligible patients, identify effective strategies to target PrEP enrollment, and compare those patients who accepted with those who declined PrEP to evaluate barriers to enrollment.

RESULTS

Of the 94 patients reviewed, 26 patients (27.7%) were found eligible for PrEP. Of the eligible patients, 3 patients (11.5%) were enrolled, and 7 patients (26.9%) declined PrEP. The others were lost to follow-up (9 of 26, 34.6%), had no action taken on a chart note to provider (6 of 26, 23.1%), or did not have a primary care provider assigned at the local facility (1 of 26, 3.9%). The 3 patients who were successfully enrolled in PrEP were all contacted and prescribed PrEP through the infectious diseases (ID) clinic. There were no statistically significant differences between the cohorts of patients who accepted and declined PrEP.

CONCLUSIONS

The use of an HIV PrEP dashboard aided in identifying eligible patients for PrEP. Enrollment through the ID clinic was the most successful modality. Further research is needed to characterize barriers to PrEP uptake and to develop strategies to increase prescribing from non-ID providers.

Changes in Oral and Anal Sex With Opposite-Sex Partners Among Sexually Active Females and Males Aged 15 to 44 Years in the United States: National Survey of Family Growth, 2011-2019

BACKGROUND

Oral and anal sex with opposite-sex partners is common and associated with sexually transmitted infection (STI) transmission. Trends in these behaviors over the last decade, during which bacterial STI diagnoses have reached historic highs while HIV diagnoses have decreased, are not well understood. We examined recent trends in oral and anal sex and associated condom use with opposite-sex partners among females and males.

METHODS

We analyzed data from 16,926 female and 13,533 male respondents aged 15 to 44 years who reported sex with an opposite-sex partner in the past 12 months from the National Survey of Family Growth, 2011-2019. We used survey-weighted linear or logistic regression to evaluate linear temporal trends in oral and anal sex behaviors.

RESULTS

From 2011-2013 to 2017-2019, reports of oral sex and number of oral sex partners in the past 12 months increased among females (85.4% in 2011-2013 to 89.4% in 2017-2019; odds ratio [OR], 1.05 [95% confidence interval {CI}, 1.02-1.09], and β = 0.014 [95% CI, 0.005-0.023]; respectively) but not males (ranges, 87.9%-89.1%; 1.27-1.31). Condom use at last oral sex decreased among both females and males (6.3%-4.3%: OR, 0.93 [95% CI, 0.88-0.99]; 5.9%-4.4%: OR, 0.95 [95% CI, 0.91-1.00]). Anal sex (ranges, 21.0%-23.3% [females] and 23.3%-24.6% [males]), number of anal sex partners (females, 0.22-0.25; males, 0.26-0.30), and condom use at last anal sex (females, 15.3%-18.2%; males, 27.0%-28.7%) remained stable.

CONCLUSIONS

The frequency of oral and anal sex with opposite-sex partners among U.S. 15- to 44-year-olds, paired with limited and-for oral sex-decreasing condom use, demonstrates the need to understand the role of these behaviors in increasing STI diagnosis rates and the potential role of extragenital screening and condoms in reducing STI transmission.

Sexual function history taking in medicine

Sexual history taking is important for the proper diagnosis and treatment of sexual dysfunction. It is often neglected in a clinical setting and it is also underreported by patients due to stigma and hesitation. Here we have described how we should take sexual function history taking during any sexual dysfunction.

Willingness to Prescribe PrEP to Bisexual Men Depends on Genders of Their Past Partners: A Study of Medical Students in the USA

Bisexual men are at increased risk for HIV compared to heterosexual men but unlikely to use pre-exposure prophylaxis (PrEP). Given that biases may influence whether bisexual men are prescribed PrEP, we examined whether medical students' decision-making was influenced by the genders of a bisexual male patient's partners. Medical students (N = 718) were randomized to one of nine conditions where they answered questions about a bisexual male patient after reviewing his electronic medical record. We manipulated the gender of his current partner (none, male, female) and the genders of his past partners (male, female, both). Current partners were described as living with HIV and not yet virally suppressed, past partners were described as being of unknown HIV-status, and condom use was described as intermittent with all partners. When the patient was not in a current relationship, perceived HIV risk and likelihood of prescribing PrEP were lowest if he only had female partners in the past. When he was in a current relationship, perceived HIV risk and likelihood of prescribing PrEP did not differ based on current or past partners' genders. In addition, identification as a PrEP candidate, perceived likelihood of adherence, and perceived likelihood of engaging in condomless sex if prescribed were lower when the patient was not in a current relationship. Medical students appropriately prioritized the status of the partner living with HIV, but their decision-making was influenced by past partner genders when the patient was not in a current relationship. Medical students may require additional education to ensure they understand PrEP eligibility criteria and make decisions based on patients' individual presentations.

Sexual Dysfunctions in Patients Receiving Opioid Agonist Treatment and Heroin-Assisted Treatment Compared to Patients in Private Practice-Identifying Group Differences and Predictors

BACKGROUND AND AIMS

Sexual dysfunctions (SDs) show a marked impact on a person's general wellbeing. Several risk-factors like physical and mental illnesses as well as alcohol and tobacco use have to date been identified to contribute to the occurrence of SDs. The impact of opioid-agonist treatment (OAT) on SDs remains unclear, with some studies demonstrating an improvement after methadone maintenance treatment (MMT) initiation. However, no studies on the prevalence and predictors of SDs in heroin-assisted treatment (HAT) exist to date.

METHODS

A cross-sectional study was conducted with patients from a MMT center (n = 57) and a center specializing in HAT (n = 47). A control group of patients with mild transient illnesses (n = 67) was recruited from a general practitioner (GP). The International Index of Erectile Function, the Female Sexual Function Index, as well as measurements for psychological distress, depressive state, nicotine dependence, and high-risk alcohol use were employed. Patients also completed a self-designed questionnaire on help-seeking behavior regarding sexual health. Mann-Whitney-U tests and chi-square tests were performed for group comparisons and binary logistic regression models were calculated.

RESULTS

Twenty-five percent of the GP sample (n = 17), 70.2% (n = 40) of the MMT sample, and 57.4% (n = 27) of the HAT sample suffered from SDs at the time of study conduction. OAT patients differed significantly from GP patients in depressive state, high-risk alcohol use, nicotine dependence, and psychological distress. Age, depressive state, and opioid dependence predicted the occurrence of SDs in the total sample. No differences between OAT and GP patients were found regarding help-seeking behavior.

DISCUSSION

Age, depressive state, and opioid dependence predicted the occurrence of SDs in the total sample. It remains unclear whether SDs are caused by opioid intake itself or result from other substance-use related lifestyle factors, that were not controlled for in this study. A lack of help-seeking behavior was observed in our sample, underlining the importance of clinicians proactively inquiring about the sexual health of their patients.

CONCLUSION

The high prevalence of SDs observed in MMT does not differ from the prevalence in HAT. Clinicians should actively inquire about their patients' sexual health in GP and OAT centers alike.

Staff's experiences of a pilot implementation of the SEXual health Identification Tool for assessing sexual ill health among visitors to Swedish youth clinics: A focus group study

BACKGROUND

Young people are disproportionally burdened by sexual ill health. The SEXual health Identification Tool (SEXIT) was developed for use at youth clinics, to facilitate identification of visitors exposed to or at risk of sexual ill health. The aim of this study was to explore experiences of using SEXIT among youth clinic staff who participated in a pilot implementation, with a focus on usefulness, implementation determinants, and feasibility of implementing SEXIT at Swedish youth clinics.

METHODS

Four focus group discussions were conducted with youth clinic staff from three clinics. The clinics had used SEXIT systematically in consultations with all visitors for one month. Data were analysed using qualitative analysis designed for focus groups.

RESULTS

Most participants experienced that the SEXIT routines were well functioning and that using SEXIT gave a comprehensive picture of the visitor and resulted in more concrete answers, which facilitated the risk assessment. The medical staff experienced that they identified more youth at risk with SEXIT, while the psychosocial staff were less convinced. Existing challenges related to the routines at the clinics and heavy workload during drop-in hours.

CONCLUSIONS

Staff experience SEXIT as useful for identifying young people exposed to or at risk of sexual ill health. Systematic use ensures consistency and quality in assessing the visitors, which may facilitate implementation. The use of SEXIT is challenged by heavy workload, conflicting routines, and the experience that some visitors identified through SEXIT decline further care. Implementation of SEXIT in Swedish youth clinics is considered feasible.