1. Women’s Sexual Health- History Taking and Risk assessment
Dr Mo Kawsar
Consultant GUM
27th Feb 2018

2. Objectives Approach to taking a sexual health history
Phrases you might use to explore the sexual history
What challenges you might face in avoiding assumptions
Making an appropriate risk assessment
Determine if there are issues she feels unable to discuss
Apply knowledge to investigation and treatment
Determine safely if she is at immediate risk of harm

3. Principles of Sexual History taking
Confidentiality
Components
Risk assessment

4. Confidentiality General Medical Confidentiality
All NHS employees are expected to adhere to
Caldicott Principles
Guidance from the General Medical Council and Nursing & Midwifery Council
General health confidentiality in the UK is a common law duty
The duty of confidentiality to the patient is absolute except in very specific circumstances, such as when it is in the patient’s or public’s interest

5. Sexual health clinic &confidentiality
The NHS Code of Confidentiality applies to services managing STIs in England and Wales, with an additional duty of enforcement of confidentiality required by the NHS Trusts (Sexually Transmitted Diseases) Directions 2000
This means that services managing STIs must operate systems for clinical record management that does not allow disclosure
Identifying information is not shared except for the purpose of treatment of STIs or for the purpose of prevention of infection

6. Environment for sexual history-taking
welcoming, comfortable, confidential physical environment is likely to encourage openness and candour when discussing sensitive issues, such as sexual behaviour
Non-judgemental way
Consultations should take place in private settings & in a soundproof room
Requests for clinician gender on the basis of culture, religion or personal preference should be accommodated where possible

7. BASHH recommendations
Confidentiality policy should be displayed in the waiting area or otherwise made available to patients
All patients should be offered a chaperone for any intimate examination in accordance with GMC guidance
All patients should be offered a clinician of their preferred gender where possible
The utmost care should be taken to preserve the confidentiality of patients and their sexual contacts during the consultation

8. Components of a sexual history
A careful assessment of symptoms to guide the examination and testing
An exposure history to identify which sites need to be sampled and the STIs to which the patient may be at risk
An assessment of contraception use and risk of pregnancy .
Assessment of other sexual health issues including psychosexual problems
Assessing HIV, hepatitis B and C risk for both testing and prevention
Assessment of risk behaviours, which will then facilitate health promotion activity including partner notification (PN)

9. Minimum sexual history
Symptoms/reason for attendance
Date of LSC, partner’s gender, anatomic sites of exposure
Condom use and any suspected infection, infection risk or symptoms in this partner
Previous sexual partner details, as for LSC, if in the last three months
Total number of partners in last three months if more than two
Previous STIs
Last menstrual period (LMP) and menstrual pattern,
contraceptive and cervical cytology history
Pregnancy and gynaecological history
Past medical and surgical history
Medication history and history of drug allergies
Agree the method of giving results
Establish competency, safeguarding children/vulnerable adults
Asymptomatic patients
Confirm lack of symptoms
Date of LSC and number of partners in the last three months
Gender of partner(s), anatomic sites of exposure, condom
Use and any suspected infection, infection risk or symptoms in partners
Previous STIs
last menstrual period (LMP), contraceptive and cervical cytology history
Agree the method of giving results
Establish competency, safeguarding children/vulnerable adults

10. Sexual history-cont. Last sexual contact/intercourse (LSC/LSI):
The gender of partner(s)- to identify same sex partner
The type of sexual contact/sites of exposure (oral, vaginal, anal)-for sampling
Condom use/barrier use- condom promotion/risk assessment
The relationship with the partner (live-in, regular, casual partner, etc.), duration of the relationship and whether the partner could be contacted- facilitate PN
The time interval since the LSI- window periods, PEP,EOC
Any symptoms or risk factors in the partner- identify STI in partner
Previous sexual contact/inter course (PSI) last three months as a minimum
Blood-borne virus risk assessment and vaccination history for those at risk
Recommend/consider
Recognition of gender-based violence/intimate partner violence(IPV)
women may be asked whether they have ever exchanged money in return for sex
Alcohol , smoking and recreational/ chem sex drug history
HPV vaccination for women after 1995

11. Risk assessment for blood-borne viruses
Current or past history of history of injecting drug misuse; sharing of needles, syringes or other drug preparation
Discussion of injecting drug misuse in sexual partners
Sex with a partner from or in a country with a high HIV, hepatitis B or Hepatitis C prevalence (NICE guidance)
HIV testing history
Hepatitis B risk and Hepatitis B vaccination history

12. Risk assessment in Children & Adolescents <18 yrs
Fraser competency/Guidelines for under 16s
The young person understands the health professional’s advice.
The young person is aware that the health professional cannot inform her parents that she is seeking sexual health advice without consent, nor persuade the young person to inform her parents
The young person is very likely to begin having, or continue to have, intercourse with or without contraceptive/sexual health treatment.
Unless she receives contraceptive advice or treatment the young person’s physical or mental health, or both, are likely to suffer
The young person’s best interests require the health professional to give contraceptive advice, treatment, or both without parental consent
Child Sexual exploitation (CSE) risk assessment
Spotting the signs- BASHH/Brook preformat

13. CSE proforma

14. Professional analysis of CSE risk
Is there evidence of any of these within their relationship?
Coercion
Overt aggression (physical or verbal)
Suspicion of sexual exploitation/grooming
Sexual abuse
Power imbalance
Other vulnerabilities
If you have identified risks or concerns please discuss with your CSE or Safeguarding Lead and follow your own child protection policy and procedure

15. Summary
Sexual history is fundamentally important to assess the sexual health of women
Detailed risk assessment is need for vulnerable females