NSW Health Sexual Health Services - Standard Operating Procedures manual

NSW Sexually Transmissible Infections Programs Unit

Section 6: Clinical Consultation
Sexual health history

  • Introduction

    A sexual health history (face-to-face or web-based applications) is obtained from each patient to:

    • identify specific risk behaviours
    • assess symptoms to guide examination and testing
    • identify anatomical sites for testing based on risk
    • inform the counselling process, health education required and contact tracing or partner notification.

    Additional history and assessment such as pregnancy and contraception based on presenting issue or diagnosis are undertaken.

    Assessment may identify opportunities for additional health interventions including referrals to allied health services, e.g. smoking cessation, mental health, drug and alcohol.

    For young people aged 12–24, a youth health and wellbeing assessment is undertaken to identify areas of concern as early as possible. See NSW Youth Health and Wellbeing Assessment Guideline.

  • Outcomes

    All patients have their identification checked, including best contact methods, at every visit and update.

    All clients attending a PFSHS have an STI and BBV risk assessment as part of their consultation.

    All patients attending a PFSHS have their vaccination status for hepatitis A, hepatitis B and human papillomavirus (HPV) recorded.

  • Procedure

    Approach to a face-to-face consultation

    • Introduce yourself and your role.
    • Students and observers should be present only with the client’s consent.
    • Create a relaxed and friendly environment. A respectful and nonjudgmental attitude should be part of the initial consultation.
    • Good communication skills, including body language, are im
    • Use plain language.
    • Provide a context for the questions to be asked and explain that there are some ‘universal’ questions that are asked of all clients to assess risk.
    • Consider the terms and language used and the assumptions made around gender, sexuality and sexual practices. Normalise potentially uncomfortable topics.
    • Start with easy questions first and move on to exploration of initial concerns, using both open and closed questions.
    • Where relevant explain confidentiality and privacy issues and their legal limitations.

    Brief sexual history

    This may include:

    • gender: the gender identity of the client, whether that gender was assigned at birth and the gender of partners
    • reason for attendance: the problem or issue, including symptoms
    • general practitioner: name; permission (or refusal) to provide clinical findings if relevant. If it is a GP referral, the GP is sent a letter summarising the consultation.
    • allergies: history of allergies, especially adverse reaction to penicillin
    • medical conditions or medication: that may influence client management
    • vaccination history: hepatitis A, hepatitis B and HPV. Use a guided history, prompting the patient’s memory of vaccination especially for hepatitis A in MSM
    • symptom review (if symptoms present): ask symptomatic and asymptomatic clients. Direct questioning may reveal overlooked or ignored problems. If symptoms present, ask type, onset, duration, severity and treatments used.
    • sexual behaviour risk assessment: last act of unprotected sexual intercourse, condom use with regular or casual partner(s), partners in the past three months, sex work
    • STI and BBV history: Past STI and BBV and treatment if known; injecting drug use
    • other history: to identify issues that may be associated with or influence client management (e.g. PrEP eligibility, drug and alcohol use including smoking, pregnancy and contraception).
  • Documentation

    Include:

    • presenting issue
    • presence of any symptoms
    • sexual health history including number and type of sexual contacts
    • STI and BBV history including vaccination for hepatitis A, hepatitis B and HPV
    • STI and BBV tests collected and specimen collection sites plus any additional serology tests
    • plans for follow-up or management (counselling, partner notification, return for vaccination)

    If undertaken, record:

    • psychosocial assessment and general health history
    • findings of physical examination (diagrams to show location of signs are acceptable)
    • rationale where clinical management such as tests taken are outside recommended guidelines
    • referrals made to allied health services, general practice or specialist
    • letters back to referring doctor informing them of the outcome of investigations, the treatment provided and any other information necessary for continuity of care.
  • References and further reading
    1. Family Planning NSW. Reproductive & sexual health: an Australian clinical practice h 3rd ed. Ashfield (NSW): FPNSW; 2016.
    2. Brook G, Bacon L, Evans C, McClean H, Roberts C, Tipple C, et al. for Clinical Effectiveness Group British Association for Sexual Health and HIV. 2013 UK national guideline for consultations requiring sexual health history taking. International Journal of STD & AIDS. 2014;25(6):391–404.
    3. British Association for Sexual Health and HIV. Standards for the management of sexually transmitted infections (STIs). London: Medical Foundation for AIDS & Sexual Health; 2014. Available at: http://www.medfash.org.uk/uploads/files/p18dtqli8116261rv19i61rh9n2k4.pdf
    4. Queensland Health. Information for sexual health practitioners. Available at: https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/sex-health/guidelines
    5. Australasian Sexual Health Alliance (ASHA). Australian STI management guidelines for use in primary care. Sydney: ASHM; 2018. Available at http://www.sti.guidelines.org.au/
    6. Burke M, Cabrie T, Cowie B, Dore G, Duffy S, Matthews G, et al. HIV, viral hepatitis & STIs: a guide for primary care. 4th ed. Sydney: ASHM; 2014. Available at: https://ashm.blob.core.windows.net/ashmpublic/HIV_Viral_Hepatitis_and_STIs_a_Guide_for_Clinical_Care_(4th_Edition).pdf
    7. US Centers for Disease Control and Prevention. 2015 sexually transmitted diseases treatment guidelines. Atlanta (GA): CDC; 2017. Available at: http://www.cdc.gov/std/tg2015/
    8. Australasian Sexual Health Alliance (ASHA). How to take a sexual history. In: Australian STI management guidelines for use in primary care. Sydney: ASHM; 2018. Available at http://www.sti.guidelines.org.au/resources/how-to-take-a-sexual-history#how-to-take-a-sexual-history