DIAGNOSIS, TREATMENT AND PREVENTION OF STIs AND HIV
Sexual history and
examination in men and
women
Merle Henderson
Sophie Herbert
Abstract
Taking a sexual history and undertaking a genital examination are not
skills regularly used in general medicine. While the structure and pro-
cess of history-taking and clinical examination follow that seen in other
medical specialties, aspects unique to taking a history that covers inti-
mate subject matter require additional empathy, sensitivity and non-
verbal skills, to enable clinicians to obtain the information needed to
undertake an appropriately thorough assessment. Telemedicine has
also become a routinely used way to assess some patients and re-
quires some adaptation to these skills. This article aims to simplify
sexual history-taking and examination, providing tips on how to do it
well, whatever the setting.
Keywords Examination; history; men; MRCP; non-binary; safe-
guarding; sexual health; telemedicine; trans-gender; women; young
people
Introduction
The aims of taking a sexual history are to:1
 establish possible risks for sexually transmitted infections
(STIs; including blood-borne infections), enabling correct
patient advice and facilitating health promotion
 identify information that might highlight a diagnosis,
which can include assessment of other health issues such
as psychosexual problems by appropriately trained staff
 establish which tests are appropriate and which body sites
should be sampled.
Taking an individual’s sexual history can be embarrassing for
both clinician and patient. The priority is to try to make the
process feel more normal, so the individual is at ease and able to
disclose the necessary information. It is essential that this is done
in a non-judgemental manner. Failure to do this can alienate
them and any subsequent interactions, which can make giving
results and further management difficult for both parties. It is
important for clinicians to be aware of their own attitudes to
sexual behaviour and recognize that this has the potential to
affect the ability to undertake effective history-taking.
Merle Henderson MB ChB MRCP DTM&H is a Specialist Registrar in HIV
and Genitourinary Medicine at St Mary’s Hospital, Imperial College
Healthcare Trust, London, UK. Competing interests: none declared.
Sophie Herbert MB ChB MSc MRCP Dip GUM Dip HIV DFSRH is a Consultant
Physician at Northamptonshire Healthcare NHS Foundation Trust,
Kettering, UK. Competing interests: none declared.
MEDICINE 50:4
Key points
C Taking a useful sexual history relies on good communication
skills (verbal and non-verbal), rapport between patient and
clinician and a non-judgemental approach
C Confidentiality is essential
C Genital examination should be systematic, and an explanation
of the process should be given before the examination. A
chaperone should always be offered, in keeping with General
Medical Council guidance
Confidentiality
Confidentiality is paramount when dealing with matters of sexual
health and should be observed in all settings. This can be
problematic depending on the environment; for example, taking
a sexual history in a busy accident and emergency department
with only a curtain to screen patients is unlikely to yield as much
useful or accurate information as a closed private room. In some
situations, it can be better to defer history-taking if clinically
appropriate until a private soundproof space can be found. It is
important to accommodate requests for preferred clinician
gender where possible, based on culture, religion or personal
preference.
Patients should be interviewed on their own, and students
and observers should only be present with the individual’s
consent. When assessing the patient over the phone or using
video calls, it is essential to ask them if they are in a safe space,
alone and able to speak freely. If not, it is likely that the
assessment will need to be rearranged to a more convenient time.
Although patients are to some extent expecting to be asked
sensitive questions, they need to know that their information will
be treated in the strictest confidence in accordance with General
Medical Council guidance.2 It is particularly helpful when talking
to young people to explain the limits of this confidentiality at the
start of the consultation, so that if safeguarding concerns arise, or
they or another person is considered to be at risk of harm, the
young person is already aware that information may need to be
shared. The disclosure of gender identity for transgender and
non-binary patients should be considered as confidential infor-
mation and it should not be assumed that consent to disclose
other aspects of a patient’s medical history includes gender
identity, unless it has been explicitly stated.1
Communication skills
Excellent communication skills are essential when taking a sex-
ual history because of the sensitive nature of the subject matter.
The clinician’s non-verbal cues are important, including use of
appropriate body language, maintaining eye contact (where
culturally acceptable) and recognizing patient cues that might
indicate anxiety and distress. Some of these aspects are clearly
harder to interpret when using remote consultations, but it is
possible to adapt listening skills and the use of ‘checking in’ with
the patient as the consultation progresses. Initial use of open
205 Ó 2022 Published by Elsevier Ltd.
 DIAGNOSIS, TREATMENT AND PREVENTION OF STIs AND HIV
questions is helpful to establish rapport and trust between patient
and clinician. It is also useful to explain the rationale for
particular questions to set the context for the individual.
Safeguarding and mental capacity
All clinicians undertaking a sexual history should be mindful of
safeguarding issues and alert to ‘spotting the signs’ of child sexual
exploitation, child criminal exploitation and other vulnerability
factors. Taking a sexual history often engenders trust between
clinician and patient, enabling disclosures to take place. Concerns
of adult and child safeguarding issues (e.g. abuse, domestic
violence, female genital mutilation (FGM)) and mental capacity
should be escalated and referred accordingly. Where information
needs to be shared, this should be explained to the individual to
maintain trust, but safety remains paramount. If in doubt, advice
should be sought from the local safeguarding team.
Structure of history-taking
The structure of sexual history-taking is the same for those of
different genders, but specific system-based questioning varies
according to the individual’s sex. Be mindful of transgender in-
dividuals and sensitive to their needs.3 Always use the person’s
chosen name, pronoun and/or title during a consultation.
The basics of history-taking are similar to those in other
specialties:
History-taking in sexual health practice
Examples of questions to be asked
‘How do you identify your gender?’
C Is this the same gender you were assigned at birth?
‘When did you last have sex?’
‘Who was that with?’
C Regular partner or casual partner?
C Length of relationship
C What gender are your partners?
‘What type of sex did you have?’ (oral, vaginal, anal, giving/
receiving)
‘Were condoms used?’ (always, sometimes, never)
‘When did you last have sex with someone different?’
‘How many partners have you had in the past 3 months?’
Screening for blood-borne viruses. History of:
C Injecting drug use
C For men e any previous male partners
C Other risk factors, e.g. exposure to blood products before
screening or abroad, tattoos, contact with sex workers
C Contact with anyone known to have HIV or hepatitis B or C
‘Have you had any sexually transmitted infections in the past?’ To establish risks, and whether treatment was completed and partner notification
previously undertaken
Table 1
MEDICINE 50:4
 presenting complaint
 history of presenting complaint
 past medical history
 for women, gynaecological history (including previous
pregnancies, current and past contraception, cervical
cytology and results)
 drug history
 allergies
 sexual history
 social history.
Certain information about sexual partners and type of sexual
activity is necessary to enable the clinician to undertake an
appropriate assessment. Equally, some personal and probably
sensitive information is not necessary to complete their evaluation.
Sexual history
The type of detail that is required from the history varies
depending on whether the individual is asymptomatic or symp-
tomatic. There are, however, questions that should be routinely
asked; these and the rationale behind them are listed in Table 1.
Other questions now commonly asked in clinics concern
lifestyle behaviours that can affect sexual risk-taking, for
example use of alcohol, smoking and in particular recreational
drugs. In some sexual encounters, recreational drugs play a large
part in increasing risk behaviour, such as in ‘chemsex’; being
aware of this enables exploration of sexual risks and facilitates
Rationale
To identify transgender/non-binary individuals (see LGBT sexual health on pages
234e238 of this issue)
To establish the timing of sex in relation to testing and:
C Inform the patient of the need for repeat testing if still in the ‘window period’
C Consider whether emergency contraception is necessary for women
C Consider whether post-exposure prophylaxis for HIV is needed
To facilitate partner notification
To identify men who have sex with men and identify STI risk. In this group offer:
rectal and pharyngeal samples; hepatitis screening and vaccination; HPV
vaccination (up to the age of 45 years) and relevant preventative options (for
example, HIV pre-exposure prophylaxis)
To identify sites to be sampled
To undertake risk assessment and facilitate condom promotion
To establish timing of tests in relation to window periods to enable correct advice
is given
To assess risk, information to be collected as above
To assess risk and enable testing
To offer hepatitis (B, C) screening and hepatitis B vaccination where appropriate
206 Ó 2022 Published by Elsevier Ltd.
 DIAGNOSIS, TREATMENT AND PREVENTION OF STIs AND HIV

health promotion through encouraging safer sex and condom
use, regular STI testing and discussion of support available for
those with problematic drug and alcohol use.
How to ask sensitive questions
It is helpful to introduce your questions with the reasons for
asking that question, for example ‘I need to ask about the type of
sex you have with your partners so I can do the right tests.’
Clinicians new to sexual health often experience difficulties
finding the right ways of asking the sensitive questions needed
for a sexual history. It takes time to find a way that is comfortable
for both clinician and patient.
Presenting complaint
Symptoms can vary. Individuals may, for example, state:
 ‘I just want a check-up’
 ‘I noticed some pain when passing urine’
 ‘I have a new discharge that is smelly and uncomfortable.’
Many patients present with some of the symptoms listed in
Table 2. If these are not mentioned initially, it is sensible to check
for them in a symptom review.
History of presenting complaint
In order to establish more detail, ask:
 ‘How long has that been going on?’
 ‘How did it start?’ (i.e. length of symptoms, onset, course,
variability, e.g. are they worse in the morning?)
 The relationship of symptoms to sexual intercourse or
other triggers.
Past medical history
This is the same as any other history-taking but should include
asking about previously diagnosed STIs.
Gynaecological history
It is important to ask about last menstrual period, cycle length,
previous and current pregnancies, menopause (if relevant), cervi-
cal screening history and history of human papillomavirus (HPV)
vaccination (younger women). Current and previous contraceptive
methods should be discussed for those with a risk of pregnancy,
including trans men and non-binary individuals assigned as female
having vaginal sex if they have not undergone hysterectomy or
bilateral oophorectomy and do not wish to conceive.
Drug history and allergies
This is as for standard history-taking but should also include a
relevant vaccination history for the HPV vaccine. This is for all
women, as above, and men who have sex with men (MSM). In
addition a history of hepatitis A and hepatitis B vaccine should be
asked for MSM and any other ‘at-risk’ individuals.
Social history
Alcohol and recreational drug use including ‘chemsex’ should be
queried. It can be useful to ascertain the social situation at home
or work if it is relevant to how potential treatment might be
delivered or if there are safeguarding concerns such as intimate
partner violence or FGM. Enquiry into whether FGM has been
previously performed should form part of routine consultation
for all cis-gender women and patients assigned as female at birth.
Under-18s should be assessed separately using young person’s
screening questions. These are not covered here but can be found
in the British Association for Sexual Health and HIV national
guideline.4
Genital examination
Genital examination can be embarrassing for patients and clini-
cians. A chaperone should always be offered.5 If one is requested
by the individual but no one is available, consider deferring the
examination until one is available.
Examination of male and female patients varies according to
anatomy, but standard principles apply. The examination should
be explained before it is carried out, for example explaining to
women that a speculum may be needed. Clinicians should
familiarize themselves with genital anatomy before undertaking
the genital examination.
Examination of male patients
It is easiest to examine men if they are lying on an examination
couch, with the examiner on their right side. However, some
clinicians prefer to have the patient standing, particularly when
assessing for testicular changes.

Symptom enquiry
Symptom Men Women

Dysuria  Increased frequency  Increased frequency

Nocturia
Hesitancy
Terminal dribble
Discharge Penile Vaginal: usual or unusual
Rectal Smell, colour, consistency, increased amount
Pain Testicular e unilateral or bilateral abdominal Abdominal
Dyspareunia e deep or superficial
Bleeding Rectal Intermenstrual or post-coital bleeding
Urethral
Skin symptoms Itchy, sore, red, rash Itching, burning, sore, red, rash
Penile, perianal Vulval, perianal

Table 2

MEDICINE 50:4 207 Ó 2022 Published by Elsevier Ltd.

 DIAGNOSIS, TREATMENT AND PREVENTION OF STIs AND HIV
Examination of men starts with general inspection, specif-
ically looking for abnormalities or changes in anatomy, such as
circumcision, swollen or missing testicles and obvious skin le-
sions. The focus should then move to the following:
 lymph nodes (inguinal) e enlarged, tender or non-tender?
 suprapubic area, inspection for skin lesions/infestations,
palpation for tenderness if applicable
 scrotum e careful examination of the skin, overall
appearance and then contents; palpate the spermatic cord
and testes, noting any abnormalities
 penis e check the shaft and prepuce, retract the prepuce (if
present; the individual can be asked to do this) and
examine the glans, coronal sulcus and urethral meatus
 inspection of the perineal and perianal areas
 proctoscopy if required, looking at the rectal wall, tissue
friability, bleeding, discharge and masses; inspect the
anorectal junction as the proctoscope is removed. Rectal
swabs including a sample for microscopy can be taken at
this point
 finishing by taking any further swabs, including meatal
samples (see below)
 consideration of whether further generalized examination
is required depending on the differential diagnosis, for
example all lymph nodes, rest of the skin, mouth (for ul-
cers) or cardiovascular and neurological systems.
Examination of female patients
This is best achieved using a specialized couch but can be per-
formed on a flat bed.
Start with general inspection of the genital area, looking for
generalized changes, rashes, erythema and changes in the ar-
chitecture of the skin. Then focus on the following before taking
samples:
 palpation of the inguinal lymph nodes
 inspection and palpation of the suprapubic area and
abdomen
 inspection of the vulva (noting erythema, skin changes,
swelling and loss of architecture if present, vaginal pro-
lapse if evident)
 introduction of a speculum (if tolerated by patient and after
explaining the procedure). Remember to take care to use
the correct size: a small speculum might be appropriate for
petite women and adolescents
 speculum examination of:
 vaginal walls e assessing for discharge and erythema
 cervix e normal, ectropion, discharge from os, other
features, for example strawberry cervix
 inspection of the perineal and perianal area
 bimanual examination (if indicated by a history of dys-
pareunia or abdominal pain), palpate the adnexae, assess
uterine size and position, assess for cervical motion
tenderness, assess for masses and tenderness
 swabs from the posterior fornix, high vagina, cervix and
skin where necessary.
The individual’s dignity should be protected at all times. For
both men and women, use of curtains to surround the bed and a
sheet to cover the genital area before and after the examination is
essential.
MEDICINE 50:4
Sample-taking: men
Urethral: urethral samples are taken with a plastic loop or fine
swab inserted 1e2 cm into the meatus. A copious discharge can
be sampled without inserting the loop. Urethral samples should
be taken before urination. Urine should have been held for 2
hours and preferably longer. Warn the patient that passing urine
may be uncomfortable for a few hours after this test.
Rectal and pharyngeal: a loop can be used to collect discharge
present in the rectum for microscopic examination. Other swabs
can be taken from the rectal walls during proctoscopy or from
any visible lesions. Blind swabs can be taken by the clinician, or
by the patient if proctoscopic examination is not required.
Pharyngeal swabs can be self-taken (if instructions are given) but
are more commonly taken by a clinician; make sure to sweep
over the fauces on both sides.
Sample-taking: women
Vaginal samples can be taken during a speculum examination. A
loop sample of vaginal discharge can be microscopically exam-
ined (from the walls for Candida and bacterial vaginosis, and the
posterior fornix for Trichomonas). Vulvovaginal swabs can now
be used for nucleic acid amplification testing for chlamydia,
gonorrhoea and, where available, Trichomonas; these can be
taken by either clinician or patient.
Self-taken swabs in asymptomatic women have been shown
to be comparable to clinician-taken swabs in terms of accuracy.
Rectal swabs can be self-taken, as can pharyngeal swabs where
needed. In some circumstances the use of first-catch urine for
chlamydia can be used, depending on local prevalence data and
awareness of sensitivity and specificity of the test. The local
laboratory’s operating policies should be checked.
Sexual history-taking and examination in young people
Sexual history-taking in young people, particularly those <16
years of age, should be undertaken sensitively and in accordance
with recommended guidance for children and young people.5 All
patients <16 years of age should have their competency to
consent to history-taking, examination and treatment appropri-
ately documented according to Fraser guidelines.
Safeguarding issues that might be raised should be dealt
with appropriately. Flags for concern include parents or carers
not being aware of a child’s sexual activity or attendance at
clinic. Situations such as non-consensual sex and significant
discrepancy in the ages of the partners should raise concern, as
should other vulnerability factors such as self-harm, imbalance
of power, grooming and alcohol and drug misuse. All concerns
should be discussed with senior team members and escalated
accordingly (see Safeguarding, child sexual exploitation and
sexual assault p. 239e242). A
KEY REFERENCES
1 Brook G, Church H, Evans C, et al. 2019 UK National Guideline for
consultations requiring sexual history taking: Clinical Effectiveness
Group British Association for Sexual Health and HIV. Int J STD
AIDS 2020; 31: 920e38.
2 General Medical Council. Confidentiality: good practice in
handling patient information. 2017, https://www.gmc-uk.org/
208 Ó 2022 Published by Elsevier Ltd.
 DIAGNOSIS, TREATMENT AND PREVENTION OF STIs AND HIV
ethical-guidance/ethical-guidance-for-doctors/confidentiality
(accessed 6 December 2021).
3 Lewis EB, Vincent B, Brett A, Gibson S, Walsh RJ. I am your trans
patient. Br Med J 2017; 357: j2963.
4 Ashby J, Browne R, Dwyer E, et al. BASHH National guideline on
the management of sexually transmitted infections and
related conditions in children and young people. 2021,
TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of the issue or online here.
Question 1
A 19-year-old man attended a sexual health clinic for the first
time. He had sex with men (MSM). He had never had a sexual
health check-up before and had no symptoms.
What anti-viral immunization combination should be
checked in his medical history?
A. Human papilloma
B. Influenza
C. Human papilloma, hepatitis B, hepatitis A
D. COVID-19
E. Human papilloma, hepatitis B
Question 2
A 17-year-old woman presented with a new vaginal discharge.
She had a regular male sexual partner whom she had been seeing
for 6 months and who was 30 years old.
What is the most important aspect of the consultation in the
first instance?
A. Examining her with a chaperone present
B. Performing a pregnancy test
MEDICINE 50:4
https://www.bashhguidelines.org/media/1262/children-and-yp-
2021.pdf (accessed 7 September 2021).
5 General Medical Council. Intimate examinations and
chaperones. 2013, https://www.gmc-uk.org/-/media/
documents/maintaining-boundaries-intimate-
examinations-and-chaperones_pdf-58835231.pdf
(accessed 6 December 2021).
C. Checking she has had a human papillomavirus vaccine
D. Completing an under-18 safeguarding assessment for risk
E. Checking her medication history
Question 3
A 32-year-old man attended a sexual health clinic for a check-up.
He had no symptoms. He identified as male gender, different
from that assigned at birth. He had not undertaken any gender
reassignment surgery but was taking hormones and was under
the local gender identity service. He was happy to have tests for
blood-borne viruses.
From where should a Chlamydia trachomatis and Neisseria
gonorrhoeae nucleic acid amplification test sample be
taken?
A. Vagina
B. Rectum
C. Urine
D. Throat
E. Depends on the history
209 Ó 2022 Published by Elsevier Ltd.