Tips for Obtaining a Comprehensive Sexual History

1. Tips for Obtaining a Comprehensive Sexual History Terry Lee, BSN, RN, BC Nurse Educator

2. Learner Objectives • Discuss the importance of obtaining a sexual history and risk assessment • Identify effective methods to obtain a comprehensive sexual history • Identify effective questions that should be asked to assess risk for STIs.

6. STDs in the United States 19 million new infections each year Half of those occur among 15-24 yr olds STDs cost 14.7 billion dollars annually Gonorrhea and Chlamydia are usually asymptomatic Pts with STD 2-5 times more likely to acquire HIV

7. Adolescent Pregnancy: The Facts • The United States has the highest rates of teen pregnancy and births in the western industrialized world. Teen pregnancy costs the United States at least $9 billion annually. • Thirty-one percent of young women become pregnant at least once before they reach the age of 20 -- about 750,000 a year. Eight in ten of these pregnancies are unintended and 81 percent are to unmarried teens. http://www.teenpregnancy.org/resources/data/genlfact.asp

8. Common Signs or Symptoms of STDs • The most common sign or symptom of STD infection is to have NO signs or symptoms • If symptoms are present, they may include: - discharge (genitals/anus) -itching/burning - blisters - abnormal bleeding - open sores (pain/no pain) - burning w/ -urination - warts (on genitals/anus) - rash (body, palms, soles) - Abdominal pain - Painful intercourse

9. How do we know if our patients are at risk for STDs/HIV? • Infections are commonly asymptomatic, so relying on report of symptoms is not adequate • Discussions about risk behaviors are necessary.

10. Discomfort as a Barrier “Ironically, it may require greater intimacy to discuss sex than toengage in it.” The Hidden Epidemic Institute of Medicine, 1997

11. Do Providers Ask About Risk? N=208 providers % of Providers Who Assessed STD Risk N= 12.7 million visits N= 317 physicians N= 317 physicians N= 417 providers HIV Care Providers Metsch 2004 Ongoing care Private Physicians Tao 2003 Non-ID trained Physicians Duffus 2003 Primary Care Providers Bull 1999 ID trained Physicians Duffus 2003

12. Barriers to taking a sexual history • Structural barriers (time/reimbursement concerns) • Patient barriers (privacy/confidentiality concerns) • Provider barriers • Low priority given to STD prevention • Acute versus preventive role perception • Low priority given to sexual health issues • Provider discomfort discussing sexual issues • Unfamiliarity with content or language • Perceived complexity of the sexual history • Inadequate training

13. Client Centered Approach • Client is in charge/control • Clients are responsible for their own decisions and behavior changes • Options, rather than directives, are offered • Counseling is not interviewing or educating • Focus on feelings as much as information • Behavior change is a process

14. Client Centered Techniques • Active Listening • Attending • Open-ended questions • Reflections • Clarifying • Articulating non-verbal messages

15. Attending • Physically showing the client you are listening • Using positive nonverbal communication

16. Open Ended Questions • 5 W’s and 1 H • Who • What • When • Where • Why • How

17. Open Ended Questions • Allows client to discuss their concerns • Solicits more information from client • Reinforces that clients have existing knowledge and skills • Elicits more information quickly

18. Reflections • Assures the patient that you have heard and understood what he/she is saying • To summarize in your own words what the patient tells you • Links material learned over the course of the interaction • Reinforces what has been discussed

19. Reflective Listening 12 approaches that are NOT reflective: Ordering, directing, commanding Warning cautioning Giving advice, providing solutions Lecturing, persuading Blaming, criticizing, disagreeing Approving, agreeing, praising Interpreting, analyzing Consoling, reassuring, sympathizing Changing the subject Questioning or probing

20. Clarifying • Clarifying: to make clear or easier to understand by explaining in greater detail • Goes hand in hand with reflections -”When you say you have sex, what exactly do you mean?”

21. Articulating non-verbal messages Be aware of: body language facial expressions eye contact if/when appropriate voice tone

22. Set the Stage: • Introductions • Private space or setting • Build rapport • Acknowledge clients feelings and the difficulty in disclosing • Be aware of facial expressions, body language, and other non-verbal ques.

23. Prepare the Client • Assure confidentiality • Assure the questions are asked of all patients • Use lead in questions for difficult or sensitive information • Be sensitive • Stress health issues related to sexual behaviors • Explain how the information will help you care for the patient

24. Key Points to Obtaining a Sexual History • Make no assumptions • Ask all patient about gender and number of partners • Ask about specific sexual practices • Vaginal, anal and oral sex • Be clear • Avoid medical jargon • Restate and expand • Clarify stories when necessary • Be tactful and respectful • Be non-judgmental

25. Key Points to Obtaining a Sexual History cont… • Risk Perception Never assume that the patient understands his/her risk for contracting a STI. Pts will often see their own risk very differently than clinicians:

26. Risk Perception • How at risk do you feel for contracting HIV or STIs? • On a scale from 1-10 with 1 being low and 10 being high, how at risk do you feel… • What do you do to protect yourself? • Out of the last 10 times you had sex, how many times did you use a condom?

27. Key Questions to Ask • Who, What, How: • Who: are you having sex with men, women, or both? How many people have you had sex with in the past 3 months? • What: what types of sex do you engage in, vaginal, anal or oral. • How: how do you protect yourself against STIs and HIV?

28. Open Ended Questions • 5 W’s and 1 H • Who • What • When • Where • Why • How

29. Chief complaint General health history Allergies Recent medication Past STDs Women: brief Gyn history HIV risk factors (IVDU, partner’s status) HIV testing history Past and current sexual practices Gender of partners Number of partners Most recent sexual exposure New sex partners Patterns of condom use Partner’s condition Substance abuse Domestic violence issues Sexual History - Content

30. Sample History: • What brings you to the clinic today? • Symptomotalogy • Past STDs • Sexual History • When was the last time you had unprotected sex? • How many people have you had sex with in the past 3 months? • Female, male or both? • What types of sex: vaginal, oral, anal?

31. Case Sample • Henry is a 35 yr old male patient who comes to the clinic today to get tested. Henry states that he is worried and just wants to be checked and treated for everything. • Where do we start?

32. Henry Case Study • Henry, I understand that you have some concerns and are feeling worried. First, let me reassure you that everything we discuss is confidential. I will need to ask you some rather personal questions, but ask all my patients these questions to help me determine how best to care for them.

33. Henry cont… • So what brings you in today? • What symptoms you are having? • Can you tell me what has you worried about STIs?

34. Henry cont… • Remember to use reflections regarding the statements Henry makes. • Always clarify any information that is not clear, never assume. • Who, What, How: • Who do you have sex with? • What types of sex do you engage in? • How do you protect yourself from STIs/HIV

35. Henry cont.. • Utilizing the Who, What and How technique: you learn that Henry is married. He had a “brief” sexual encounter (he received and gave oral sex) with a old male friend recently and now thinks he may have an infection or HIV. Henry states he never uses condoms with his wife and this is his first encounter with another male. He us usually monogamous.

36. Henry… • What are important next steps:

37. Native American Patient Considerations • I wish to acknowledge Robert Foley, Program Director of National Native American AIDS Prevention Center (NNAAPC) for the information provided in the next few slides • www.nnaapc.org • Robert Foley 720-382-2244/303 • rfoley@nnapc.org

38. Native American Patients: Things to Keep in Mind • Speak with the patient not at or to him/her. • Know the meaning of eye contact • Understand that emotions may not be shown on patient’s face • Pay attention to subtle body language • Do not force your opinion on patient • Allow for time to process information • Do not speak fast, rather speak clearly and slowly

39. Things to Keep in Mind cont… • Cherish the time you have with patients, build a rapport and trust, this facilitates communication, sharing and confidence • Take time for small talk, it builds rapport • Answer all questions in layman’s terms, avoid jargon and abbreviations • Pay close attention to stories, this is a communication technique for Native American people, if you do not understand the meaning, ASK.

40. Things to consider: • Do not ask more than one question at a time, ask a question and wait for a response, if needed seek clarification before asking the next question. • Do not expect pt to make all treatment decisions immediately, some may leave and return with a decision at a later time.

41. Conclusion • Obtaining a comprehensive sexual history may seem daunting at first, but with consistency and practice, it can actually make it easier to assess patients for risk, and help them develop a risk reduction plan. • Remember your patients are experts regarding their behavior, and you are the expert regarding STIs. Utilizing a client centered approach is an ideal way to address risks.

42. Online Resources The Internet and STD Center for Excellence presents: www.STDPreventionOnline.org Free for individuals and organizations Provides resources, discussions, jobs, STD information, and upcoming events

43. References • Centers for Disease Control. Sexually Transmitted Diseases. http://www.cdc.gov/std/stats07/trends.htm • Center for Disease Control. Project Respect. http://www.cdc.gov/hiv/topics/research/respect/index.htm • Creegan, L. MS, FNP. An Introduction to Taking a Sexual History. California STD/HIV Prevention Training Center

44. www.denverptc.org

45. National Network of STD/HIV Prevention Training Centers www.NNPTC.org