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Intro to taking a Sex History Linda Creegan 1


									   An Introduction to
 Taking a Sexual History
and Client-Centered Risk-
  Reduction Counseling
            Linda Creegan, FNP
   California STD/HIV Prevention Training
            STD Clinical Series
    STDs in the New Millennium:
       Scope of the Problem
n   STDs are among the most common infectious
    diseases in the U.S. today
    u   Chlamydia is the most common reportable disease
    u   About 1 in 5 adults has HSV-2; HPV is even more
        common in some populations
n   STDs increase transmission risk for HIV by 2-
    5 fold
n   Current syphilis outbreaks in many urban
    centers including Honolulu, SF, LA , NY,
A Sexual History is an essential part
     of many provider/patient
 u Allows individualization of STD/HIV
   diagnosis and screening
 u Guides counseling through risk
 u Allows patient to express concerns
   and ask questions
 u Enables appropriate referrals
     …However, it is often given
                          short shrift.
n   Fewer than half of physicians report taking a
    sexual history from their patients
    u   40% of MDs screened teen patients for sexual activity
    u   15-40% asked questions of adult patients about # and
        gender of partners, and condom use

n   Kaiser Family Foundation patient survey,
    u   39% were asked about sexual history
    u   12% were asked about STDs
    u   83% felt STDs should be discussed at a first-time Ob/Gyn
Millstein et al, Jour. Adol. Med., Oct, 1996 Haley et al, AJPH, June 1999
                      Why is this?
n   Structural barriers (time/reimbursement concerns)
n   Patient barriers (privacy/confidentiality concerns)
n   Provider barriers
    u   Low priority given to STD prevention
         l   Acute versus preventive role perception
         l   Low priority given to sexual health issues
         l   Devaluation of behavioral interventions
    u   Provider discomfort discussing sexual issues
         l   Concern for patient privacy
    u   Unfamiliarity with content or language
         l   Perceived complexity of the sexual history
         l   Inadequate training
     Primary Factors in Taking a
           Sexual History
n   Ensure privacy and confidentiality
n   Establish rapport
n   Accurately define the problem(s)
n   Determine the level of HIV risk
n   Ensure successful patient management
    u   Diagnosis and treat symptomatic disease
    u   Detect asymptomatic disease
    u   Prevent serious sequelae, (i.e.infertility in women)
    u   Promote behavior changes to prevent future
       Who is most at-risk for an
            Risk Factors and Markers
n   Young age (15-35)       n   Sexual practices or
n   Higher prevalence in        behaviors
                                u   multiple partners
    urban areas
                                u   new partner
n   Disproportionately          u   casual partners
    affect those of lower       u   improper or
    economic status                 inconsistent condom
n   Exposure to an STD
                                u   earlier age at first
n   History of certain              sexual activity
      Who is most at-risk for an
            Presenting Symptoms
n   Discharge (vaginal,   n   Itching
    urethral, rectal)     n   Pain
n   Vaginal odor          n   Swelling
n   Dysuria (frequency,   n   Change in bowel
    urgency)                  habits
n   Skin lesion(genital   n   Vaginal or rectal
    or extragenital)          bleeding
n Rash                n Sexual dysfunction

Remember: Many STDs give no symptoms.
          Introducing the Sexual
n   Acknowledge personal nature of the subject
n   Emphasize confidentiality
n   Stress health issues related to sexual
n   Be able to explain how the information will
    help you care for the patient
      “I’m going to ask some questions about you sexual history.
        I know this is very personal information, but it involves
       important health issues and everything we discuss is
      Sexual History - Content
n   Chief complaint           n   Past and current sexual
n   General health history        practices
                                  u   Gender of partners
n   Allergies
                                  u   Number of partners
n   Recent medication             u   Most recent sexual
n   Past STDs                         exposure

n   Women: brief Gyn          n   New sex partners
    history                   n   Patterns of condom use
n   HIV risk factors (IVDU,   n   Partner’s condition
    partner’s status)         n   Substance abuse
n   HIV testing history       n   Domestic violence
    Summary: The Five “P’s”

n   Past STDs
n   Pregnancy history and plans
n   Partners
n   (Sexual) Practices
n   Prevention of STDs/HIV
 Communication Skills to
Facilitate the Sexual History
n   Use open-ended questions rather than
    leading or “yes/no” questions
    u   Who, what, when, where?
    u   “Tell me about…”
    u   Cone Style of interviewing
n   Encourage patients to talk, when needed
    u   Permission-giving: “Say it in your own words”
    u   Give range of behavior and ask for patient’s
n   Active listening cues to urge patient on
    u   Eye contact, nodding, “Yes, go ahead”
    General Considerations for
     Taking a Sexual History
n   Make no assumptions
    u   Ask all patient about gender and number of
    u   Ask about specific sexual practices
         l Vaginal, anal and oral sex

n   Be clear
    u   Avoid medical jargon
    u   Restate and expand
    u   Clarify stories when necessary
        General Considerations for
         Taking a Sexual History
n   Be tactful and respectful
    u   Use an unrelated translator whenever
    u   Use accepting, permission-giving language
        and cues
n   Be non-judgmental
    u   Recognize patient anxiety
    u   Recognize our own biases
    u   Avoid value-laden language (“You
        should..”, “Why didn’t you..” “I think you..”)
             Primary Prevention
     Integrating Risk-Reduction Counseling into
             Routine Patient Encounters

n   A client-centered approach is most effective
n   Similar messages will help patients prevent
    HIV, STD, and unintended pregnancy
n   Emphasize remaining uninfected, by
    changing behaviors to decrease risk for
    acquisition and/or transmission of STD/HIV
     Client-Centered Counseling:
     n   Counseling conducted in an interactive
         manner through the use of open-ended
         questions and active listening, which
         focuses on developing prevention
         objectives and strategies with the client
         rather than simply providing information.

CDC HIV Prevention Case Management Guidelines, 1997
         Factors that Affect
          Behavior Change
n   Knowledge             n   Actual
n   Perceived risk            consequences
n   Perceived             n   Access
    consequences          n   Intentions
n   Attitudes (beliefs)   n   Perceived social
n   Skills                    norms
n   Self -efficacy        n   Policy
     Counseling vs. Education
n   Dialog                 n   One-way
n   Individualized         n   Levels of detail but
n   Takes feelings and         not tailored to an
    beliefs into account       individual

n   Helps client           n   Sticks to the facts
    understand             n   Helps client
    themselves better          understand a
n   Short and focused          subject better
                           n   Short and focused
     Project Respect - A Relevant Model
        for STD/HIV Clinical Settings
n   Large, randomized, multi-center study funded by
    CDC, completed in 1997
       l   Evaluated efficacy of STD/HIV prevention counseling in
           changing risky sex behaviors and preventing new STDs
       l   Almost 6000 patients attending large publicly-funded
           STD clinics (SF, LB, Denver, Baltimore, Newark)
       l   Patients received client-centered counseling by
           trained (non-clinical) staff
       l   Outcome measures:GC,CT,Syphilis, HIV
n   Findings: two short counseling sessions (20
    minutes each) successfully increased condom
    use and prevented new STDsKamb et al, JAMA Oct.7,1998
    General Principles for Client-
       Centered Counseling
n   Approach each patient as an individual
n   Focus first on issues and realities that the
    patient identifies
n   Use open-ended questions and active
    listening skills to establish a dialog
n   Maintain a neutral, non-judgmental attitude
n   Offer options, not directive
n   Onus of action and responsibility remains with
    the patient
     Three Steps in a Client-
     Risk Reduction Session
n   Focus on personal risk assessment
    u   Identify patient’s personal perception of risk

n   Identify safer goal behaviors
    u   Identify patient’s level of readiness for change
    u   Assess barriers to behavior change efforts

n   Develop a personalized action plan
    u   Negotiate small, realistic risk-reduction steps
    u   Refer to specialized services, if needed
              Assess Client Risk
Begin dialogue with patient to determine
    u   number, gender of partners
    u   sexual practices (anal, oral, vaginal sex)
    u   patterns of condom use
    u   prior STD testing history, and diagnoses

n   Identify factors affecting patient risk
    u   current/past history of unprotected sex
    u   intentions for becoming pregnant
    u   history of domestic violence
    u   history of injection drug use
      Sample Risk Assessment
·   What are you doing in your life that might be
    putting you at risk for STD/HIV?
·   What are the riskiest things that you are doing?
·   What are the situations in which you are most
    likely to be putting yourself at risk for HIV or
·   What is your experience with shooting up
·   When was the last time that you put yourself at
    risk for STD/HIV? What was happening then?
·   When do you have sex without a condom?
·   How do drugs or alcohol influence your STD or
    HIV risk behaviors?
    Assess Personal Perception
              of Risk
n   Identify factors affecting patient’s personal
    perception of risk (knowledge, attitudes,
    Note: if perception of risk is not accurate, counselor
     assists patient in recognizing risk
n   Consider patient’s level of readiness for
    u   Pre-contemplation
    u   Contemplation
    u   Preparation
    u   Action
    u   Maintenance
       Safer Goal Behavior
n   How would you like to change that?
n   What would you like to do differently?
n   What might be better for you to do?
 Client Centered Counseling

Risk Behavior      Safer Goal Behavior
Unprotected        Consistent condom
vaginal sex with   use with this partner
new partner
Possible Goal Behaviors for
   STD Risk Reduction
n   Reducing # of sexual partners
n   Increase in condom use with main/non-
    main partners
n   Partner testing
n   Monogamy
n   Abstinence
n   Consideration of any of the above
 Client Centered Counseling

Risk Behavior           Safer Goal Behavior

                Factors that
   Barriers     influence         Benefits
Identify Barriers/Sources of
    Support for Change
n   Personal perception of risk
n   Self efficacy related to negotiating safer
n   Power and control dynamics in
n   Cultural issues
n   Access to care
n   Significant others
Client Centered Counseling
  Risk Behavior                   Safer Sex Goal

 Barriers        Factors that          Benefits
                 influence behavior

            Personalized Action Plan
Negotiate Realistic, Simple Risk
 Reduction Steps with Patient

Risk reduction plan must be patient-driven,
  based on pt. history, readiness, & ability
  to adopt safer behaviors

Health care providers should:
  u   support efforts previously attempted by
  u   offer options, not directives
  u   remain non-judgmental
    Personalized Action Plan
n   How will you go about that?
n   What will you need to do first/next?
n   When will be a good time to try/begin
n   What is one thing you could do to
n   Who can you talk to about this for
    Refer to Specialized Services,
              If Needed

n   Alcohol or drug treatment programs
n   Partner/domestic violence services
n   Partner counseling and referral services
n   Couples counseling
n   Benefits counseling to obtain access to
           Taking Personal Stock
n   Helping clients change behavior may
    begin with changing some of our own
    u   Recognize our biases and keep them in
    u   Talk less, listen more
    u   Encourage step-wise, incremental, realistic
    u   Avoid “should/shouldn’t”,”I think you…..”
        “You need to…..”
    u   Be willing to give it a try!

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