Chapter 18Detailed Sexual Histories

• Normalizing Opening Statements¹: Is it okay if I ask you a few questions about your sexual health? Some of questions are very personal. I ask everyone these questions, and I consider them to be very important. You do not have to answer any questions you don’t want to.
• Confidentiality Statement: As with all of our visits, the information we discuss will be kept confidential. I might take notes and put those in your record here, but everything will be stored securely. There are some instances where I may be required by law to break confidentiality, for example if I believe there is immediate risk of harm to yourself or others. Does this sound okay with you?
• General Sexual History²³:
  • Have you been sexually active in the past year?
  • How many partners have you had sex with in the past year?
  • What is your partner’s gender? What gender or genders are the partners you’ve had sex with in the last year?
  • Do you have any sexual concerns you would like to discuss?

Why Ask: An understanding of current sexual function and practices is an important part of a patient’s history. A sexual history should be taken as part of a comprehensive health assessment – for example, during a patient’s initial visit, during routine preventive exams, or if there are concerns for Sexually Transmitted and Blood Borne Infections (STBBIs) for example. A sexual history identifies important current and past patient risk factors. In gathering a sexual history, it is important to remember that sexual behavior and not sexual identity puts individuals at risk for unplanned pregnancy and for contracting STBBIs - do not make assumptions about behavior or risk based on sexual orientation or gender. If concerns are raised, initial sexual history questions can be further explored as part of a Detailed Sexual History (see Below) including the 5Ps of Harm Reduction – Practices; Partners; Protection from Sexually Transmitted and Blood Borne Infections (STBBIs); Past History of STBBIs; and Pregnancy. Key Idea: Social history includes, but is not limited to, sexual health and substance use history.

Adopting a sex-positive approach means respecting the wide range of human sexuality. It involves talking with patients openly and without judgment about their sexuality. A sex-positive approach respects the sexual rights of all persons, and also acknowledges that not everyone has learned about or experienced sexuality in a positive and affirming way.

Sexuality is more than sexual activity. It is made up of complex and dynamic forces that influence an individual’s sense of identity, social well-being and personal health. It involves sex, gender identities and role, sexual orientation, eroticism, pleasure, intimacy and reproduction. It is experienced and expressed through thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships.

Harm Reduction refers to policies, programs and practices that aim to minimize negative health, social and legal impacts associated with drug use, drug policies and drug use. Harm reduction is grounded in justice and human rights – it focuses on positive change and on working with people without judgment, coercion, discrimination, or requiring that they stop using drugs as a precondition of support. Principles of Harm Reduction include respecting the rights of people who use drugs; a commitment to evidence; a commitment to social justice and collaborating with networks of people who use drugs; and the avoidance of stigma. Goals of Harm Reduction include keeping people alive and encouraging positive change in their lives; reducing the harms of drug laws and policy; and offering alternatives to approaches that seek to prevent or end drug use.⁴ A recent paper describes 6 principles of Harm Reduction which can be generalized to working with other chronic conditions: Humanism; Pragmatism; Individualism; Autonomy; Incrementalism; and Accountability without termination.⁵

Social determinants of health are specific to the social and economic conditions that shape the health of individuals, communities and countries. They influence the extent to which individuals have the physical, social and personal resources to achieve their goals, satisfy their needs, and cope with their environments. In Canada, 12 social determinants of health are recognized: (1) Physical environment; (2) Employment and working conditions; (3) Social environment; (4) Social support networks; (5) Health services; (6) Culture; (7) Income and social status; (8) Education and literacy; (9) Personal health practices and coping skills; (10) Healthy child development; (11) Biology and genetic endowment; and (12) Gender.

In the context of STBBIs, structural and social conditions such as the social determinants of health can impact a patient’s ability to start and maintain STBBI prevention practices. Attending to the social determinants of health can help create opportunities to improve the lives of patients, including but not limited to advocate for patients to access services (micro-level intervention); to build capacity of community level programs (meso-level); and to advocate for policy changes (macro-level).

Trauma Informed Care (TIC)⁸ is a strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma. It emphasizes physical, psychological, and emotional safety for both providers and survivors, and creates opportunities for survivors to rebuild a sense of control and empowerment. A Trauma-informed approach to care is relevant to all areas of medicine, and is particularly salient in discussing sexual history, sex partners or sexual practices. One helpful framework for TIC is the Four C’s - Calm, Contain, Care and Cope. This is explored in Appendix 1 – Important patient-physician communication skills – MF1, including information about Adverse Childhood Experiences (ACEs).

Trauma-and Violence-Informed Care (TVIC)³ takes this a step further to recognize and work with the broader social and structural conditions that impact health, including institutional policies and practices. The idea is that organizational policies and practices, as well as individual provider practices do not lead to re-traumatization of clients. Example strategies include acknowledging the effects of historical and structural conditions; seeking patient input about safe and inclusive strategies; and encouraging patient empowerment in choosing their care options and adopting harm reduction strategies.

Introductory statement¹: I need to ask some more specific questions about the kinds of sex you have had over the last 12 months to better understand if you are at risk for STIs. We have different tests that are used for the different body parts people use to have sex. Would that be okay?

1. Are you currently sexually active? (Are you having sex?)
   • If not: Have you ever been sexually active?
2. What kind of sex do you have (or have you had in the past?)
   • Vaginal sex (penetration of vagina)
   • Anal sex (penetration of anus)
   • Oral sex (mouth on penis/vagina/anus)
   • Manual stimulation of penis/vagina/anus?
3. Are you the insertive or receptive partner, or both? (Are you a top or a bottom?)
4. Have you ever shared sex toys? If so, was a barrier of some kind used?
5. Have you ever had sex when you didn’t want to?
6. Have you ever been hurt or injured during sexual activity? Do you experience pain while having sex?
7. Have you ever been given a tattoo or piercing with a non-sterile needle?
8. Have you noticed any changes to your sexual desire or libido?

Note: You may also need to ask Expanded Substance Use History depending on patient care needs.

1. How many different people have you had sex with in the past 2 months? In the past year? (Or: Have you had sex with multiple people in the past 2 months, in the past year?)
2. Have you had any recent new sex partners?
3. What is/are the gender(s) of your sex partner(s)?
4. Do you ask about your partners’ sexual health history or history of STBBIs before having sex?
5. Do you use substances while having sex? Who do you normally use substances with?

1. Can you share with me what you know about protecting yourself and your partners from STBBIs?
2. Do you or your (regular and non-regular) partners use any barriers during sex (i.e. condoms, dental dams, split condoms/gloves)?
   • When do you use them (i.e. all the time, sometimes, never) and for what kind of sex (i.e. vaginal sex, oral sex, anal sex, manual stimulation)?
3. Do you have any problems related to the use of barriers (e.g. cost, partners not wanting to use them, do not know how to use them, etc.)?
4. What questions (if any) do you have about different barrier methods?
5. Do you know where to get low-cost or free barrier methods in your community?
6. Have you been vaccinated for HPV (i.e. Gardasil)? Hepatitis A? Hepatitis B?
7. Are there any other things you do to protect yourself from STBBIs (e.g. using sterile injection equipment, not sharing substance use equipment, not using when you’re alone, taking your antiretroviral medication regularly, use of Pre-Exposure Prophylaxis (PrEP) for HIV)?

1. Have you ever been tested for HIV or other STBBIs?
2. Have you ever had a Pap test (or pap smear) and/or pelvic exam?
   • a. If yes: When was your last Pap test? Do you know if you were screened for HPV?
3. Have you ever had an STBBI?
   • a. If yes: When? Were you treated? Do you know how you were treated? Did you retest after you finished treatment? Do you have any ongoing problems or concerns?
4. Do you know if any of your current or past sexual partners have had an STBBI?
   • a. If yes: Were you tested? Were you treated? Do you know how you were treated? Did you retest after you took the treatment?
5. Do you have any signs or symptoms that worry you – any lumps, bumps, discharge or pain?
6. Would you like to be tested?
   • a. If yes: What questions do you have before we do the testing?

1. Is there any chance that you could be pregnant now?
2. Are you or your romantic or sexual partners trying to get pregnant?
3. Are you or your romantic or sexual partners interested in becoming pregnant in the future?
4. How important is it to you to prevent pregnancy (until then)?
5. Have you been pregnant before? → If Yes: Assess GTPAL (Gestation, Term, Preterm, Abortion, Living Children – explored in Ch 19 – Sensitive Pelvic Exams – MF3)

1. Is there anything else you’d like to discuss that’s impacting your health or well-being?
2. Is there anything that we discussed earlier that you’d like to revisit?
3. What other questions do you have?
4. Is there any other information I can give you to support your health and well-being? Are there any support or referral services that you’d like to talk about?

Building on the General Sexual History in Chapter 1 (in MF1), you may wish to include the following Basic Sexual Function Screening¹⁰:

1. Are you currently involved in a sexual relationship?
2. If yes: How would your partners identify themselves in terms of gender? Any concerns or pain with sex?
3. If no: Any sexual concerns you would like to discuss or that have contributed to lack of sexual behavior?

Do you have any sexual health concerns? Specifically, any distress related to:

1. Your level of sexual desire/interest?
2. Your ability to become or stay sexually aroused (“turned on”, vaginal lubrication, blood flow/warmth/tingly feelings in genitals?)
3. Your ability to experience or reach the desired intensity of an orgasm?
4. Are you experiencing any genital pain?
5. Are you experiencing vaginal dryness or burning?
6. Are you experiencing pain with sexual activity (insertional or deeper pain)?

Each item scored on a scale of 1-5; Score <20 = Erectile dysfunction

1. How would you rate your confidence that you could get an erection?
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
5. When you attempted sexual intercourse, how often was it satisfactory to you?
6. Other Questions as part of Sexual Health Inventory for Men (SHIM):
   • Have you discussed your Erectile Dysfunction (ED) issues and concerns with your partner?
   • Is your partner willing to attend appointments with healthcare professionals with you to learn more about this problem?

1. Maintain: On a scale of 0 - 10 (and rotate your arm up like 9 o’clock to 12 o’clock)
2. Normalization: Reassure patient that it is a medical issue that affects 40% of males at some point in their lives at least occasionally (or can just say it is common)
3. Prepping Patient for Difficult Questions: Let the patient know and determine consent before asking personal questions (specifically sexual history questions), and relate it back to how it will help you provide best care

• Autonomics (Point and Shoot re PNS → SNS; Erection → Orgasm)
• Blood Flow (small vessels) - VASCULAROPATHY: Angina of the Penis
• Libido (Androgens re gonad functioning)
• Causes of De-Tumescence Physically:
  • Vasculogenic: Cardiovascular disease, hypertension, diabetes mellitus, hyperlipidemia, smoking, major surgery (radical prostatectomy) or radiotherapy (pelvis or retroperitoneum).
  • Neurogenic: Spinal cord and brain injuries, Parkinson disease, Alzheimer disease, multiple sclerosis, stroke, major surgery (radical prostatectomy) or radiotherapy of the prostate.
  • Local penile (cavernous) factors: Peyronie’s Disease (90 degree angle, the fibrous tissue can get fractured more easily); Cavernous fibrosis, penile fracture.
  • Hormonal: Hypogonadism, hyperprolactinemia, hyper- and hypo-thyroidism, hyper- and hypo-cortisolism
  • Drug Induced: Antihypertensives, antidepressants, antipsychotics, antiandrogens, recreational drugs, alcohol

• Stress: Vicious feedback loop (diagram below)
• Multiple partners: if they do have multiple partners, does the issue present during sexual contact with some or all of them?
• Masturbation: is the patient capable of orgasm through self-stimulation?
• Waking up with erection: one way of trying to assess whether the patient ever has erections
• Sexual Trauma – History of sexual abuse, nervousness around sexuality

Increased Performance Anxiety → Decreased Performance → Increased Stress → Increased Performance Anxiety

• Sildenafil, Tadalafil, Vardenafil → Phosphodiesterase-5 (PDE-5) Inhibitors re vasodilation tone
  • CONTRAINDICATION TO TAKE WITH NITROGLYCERINE (Risk of hypotension)
• External Pumps
• Prostaglandin injection (could be an option for the patient who would benefit from PDE-5 inhibitor and is on Nitroglycerine)

• Masters, Johnson, & Kaplan propose a linear model of sexual response for men and women, with four 4 phases:

This linear model is based on a male model, adapted to female sexual function. Female sexual responses may occur in a non-linear way, may not experience orgasm, or experience > 1. Sexual satisfaction does not correlate to adherence to a linear model¹⁵

• Estrogen is responsible for maintaining healthy vulvovaginal mucosa with adequate lubrication
  • When estrogen levels decline, such as around menopause, women commonly experience a decrease in vaginal lubrication, vaginal tissue elasticity, clitoral sensitivity, and overall sexual response¹⁶
  • Those with cyclical libido changes often experience a peak around ovulation and menses.
• There is some evidence that androgens, like testosterone, play a role in libido, arousal, and orgasm¹⁷.
  • Hormonal conditions affecting HPO axis (e.g. hyperprolactinemia, hypothyroidism) can also affect libido.
• Neurotransmitters play a role in sexual desire, as evidenced by impaired libido with many SSRIs and SNRIs. Conversely, Levodopa, which primarily acts via dopamine, is associated with increased libido.

• Normalize: reassure patients that sexual problems are common in female sexual function and recognize that this topic is difficult to discuss. Framing them as “couple” problems can also lessen self-blame.
• Prepare patients for difficult questions: obtain consent to discuss personal topics (e.g. prior sexual experiences, challenges, relationship history, and mental health. Relate it back to your ability to provide comprehensive care and reassure them of your commitment to confidentiality. Patients who want to discuss sexual problems tend to be forthcoming with information.
• Clear up misconceptions. For example, share with patients that women commonly report not feeling desire prior to sexual activity, or that some do not always orgasm¹⁷. Be mindful of your own beliefs and biases around sex.

• PLISSIT Approach: Permission (create space to discuss sex), Limited Information (provide facts), Specific Suggestions (opportunities to optimize sex through medication or behavioural change), Intensive Therapy as needed.
• Lifestyle modification: optimize sleep, diet & exercise, stress management, patient education¹⁵
• Sexual aids: lubricants (especially for peri- & post-menopause), sex toys, sex positive books or other media¹⁵
• Counseling: address relationship issues, sex therapy, therapy for mental health (e.g. CBT), trauma-focused therapy¹⁷
• Hormonal androgens: testosterone therapy modestly improves libido & sexual frequency post-menopausal women¹⁴¹⁷
• Serotonergic or dopaminergic agents: flibanserin (Addyi) and bupropion may increase sexual satisfaction and desire¹⁴