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An Introduction to Taking a Sexual History and Client-Centered Risk- Reduction Counseling. Linda Creegan, FNP California STD/HIV Prevention Training Center STD Clinical Series. STDs in the New Millennium: Scope of the Problem.

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an introduction to taking a sexual history and client centered risk reduction counseling

An Introduction toTaking a Sexual Historyand Client-Centered Risk- Reduction Counseling

Linda Creegan, FNP

California STD/HIV Prevention Training Center

STD Clinical Series

stds in the new millennium scope of the problem
STDs in the New Millennium:Scope of the Problem
  • STDs are among the most common infectious diseases in the U.S. today
    • Chlamydia is the most common reportable disease
    • About 1 in 5 adults has HSV-2; HPV is even more common in some populations
  • STDs increase transmission risk for HIV by 2-5 fold
  • Current syphilis outbreaks in many urban centers including Honolulu, SF, LA , NY, Chicago
a sexual history is an essential part of many provider patient interactions
A Sexual History is an essential part of many provider/patient interactions….
  • Allows individualization of STD/HIV diagnosis and screening
  • Guides counseling through risk assessment
  • Allows patient to express concerns and ask questions
  • Enables appropriate referrals
however it is often given short shrift
…However, it is often given short shrift.
  • Fewer than half of physicians report taking a sexual history from their patients
    • 40% of MDs screened teen patients for sexual activity
    • 15-40% asked questions of adult patients about # and gender of partners, and condom use
  • Kaiser Family Foundation patient survey, 1997
    • 39% were asked about sexual history
    • 12% were asked about STDs
    • 83% felt STDs should be discussed at a first-time Ob/Gyn visit

Millstein et

al, Jour.




., Oct, 1996 Haley et al, AJPH, June 1999

why is this
Why is this?
  • 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
      • Devaluation of behavioral interventions
    • Provider discomfort discussing sexual issues
      • Concern for patient privacy
    • Unfamiliarity with content or language
      • Perceived complexity of the sexual history
      • Inadequate training
primary factors in taking a sexual history
Primary Factors in Taking a Sexual History
  • Ensure privacy and confidentiality
  • Establish rapport
  • Accurately define the problem(s)
  • Determine the level of HIV risk
  • Ensure successful patient management
    • Diagnosis and treat symptomatic disease
    • Detect asymptomatic disease
    • Prevent serious sequelae, (i.e.infertility in women)
    • Promote behavior changes to prevent future infections
who is most at risk for an std risk factors and markers
Young age (15-35)

Higher prevalence in urban areas

Disproportionately affect those of lower economic status

Exposure to an STD

History of certain STDs

Sexual practices or behaviors

multiple partners

new partner

casual partners

improper or inconsistent condom use

earlier age at first sexual activity

Who is most at-risk for an STD?Risk Factors and Markers
who is most at risk for an std presenting symptoms
Discharge (vaginal, urethral, rectal)

Vaginal odor

Dysuria (frequency, urgency)

Skin lesion(genital or extragenital)





Change in bowel habits

Vaginal or rectal bleeding

Sexual dysfunction

Who is most at-risk for an STD? Presenting Symptoms

Remember: Many STDs give no symptoms.

introducing the sexual history
Introducing the Sexual History
  • Acknowledge personal nature of the subject matter
  • Emphasize confidentiality
  • Stress health issues related to sexual behaviors
  • 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 confidential”

sexual history content
Chief complaint

General health history


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
summary the five p s
Summary: The Five “P’s”
  • Past STDs
  • Pregnancy history and plans
  • Partners
  • (Sexual) Practices
  • Prevention of STDs/HIV
communication skills to facilitate the sexual history
Communication Skills to Facilitate the Sexual History
  • Use open-ended questions rather than leading or “yes/no” questions
    • Who, what, when, where?
    • “Tell me about…”
    • Cone Style of interviewing
  • Encourage patients to talk, when needed
    • Permission-giving: “Say it in your own words”
    • Give range of behavior and ask for patient’s experience
  • Active listening cues to urge patient on
    • Eye contact, nodding, “Yes, go ahead”
general considerations for taking a sexual history
General Considerations for Taking 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
general considerations for taking a sexual history15
General Considerations for Taking a Sexual History
  • Be tactful and respectful
    • Use an unrelated translator whenever possible
    • Use accepting, permission-giving language and cues
  • Be non-judgmental
    • Recognize patient anxiety
    • Recognize our own biases
    • Avoid value-laden language (“You should..”, “Why didn’t you..” “I think you..”)
primary prevention integrating risk reduction counseling into routine patient encounters
Primary PreventionIntegrating Risk-Reduction Counseling into Routine Patient Encounters
  • A client-centered approach is most effective
  • Similar messages will help patients prevent HIV, STD, and unintended pregnancy
  • Emphasize remaining uninfected, by changing behaviors to decrease risk for acquisition and/or transmission of STD/HIV
client centered counseling definition
Client-Centered Counseling:Definition
  • 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

Perceived risk

Perceived consequences

Attitudes (beliefs)


Self -efficacy

Actual consequences



Perceived social norms


Factors that Affect Behavior Change
counseling vs education


Takes feelings and beliefs into account

Helps client understand themselves better

Short and focused


Levels of detail but not tailored to an individual

Sticks to the facts

Helps client understand a subject better

Short and focused

Counseling vs. Education
project respect a relevant model for std hiv clinical settings
Project Respect - A Relevant Model for STD/HIV Clinical Settings
  • Large, randomized, multi-center study funded by CDC, completed in 1997
      • Evaluated efficacy of STD/HIV prevention counseling in changing risky sex behaviors and preventing new STDs
      • Almost 6000 patients attending large publicly-funded STD clinics (SF, LB, Denver, Baltimore, Newark)
      • Patients received client-centered counseling by trained (non-clinical) staff
      • Outcome measures:GC,CT,Syphilis, HIV
  • Findings: two short counseling sessions (20 minutes each) successfully increased condom use and prevented new STDs

Kamb et al, JAMA Oct.7,1998

general principles for client centered counseling
General Principles for Client- Centered Counseling
  • Approach each patient as an individual
  • Focus first on issues and realities that the patient identifies
  • Use open-ended questions and active listening skills to establish a dialog
  • Maintain a neutral, non-judgmental attitude
  • Offer options, not directive
  • Onus of action and responsibility remains with the patient
three steps in a client centered risk reduction session
Three Steps in a Client-CenteredRisk Reduction Session
  • Focus on personal risk assessment
    • Identify patient’s personal perception of risk
  • Identify safer goal behaviors
    • Identify patient’s level of readiness for change
    • Assess barriers to behavior change efforts
  • Develop a personalized action plan
    • Negotiate small, realistic risk-reduction steps
    • Refer to specialized services, if needed
assess client risk
Assess Client Risk

Begin dialogue with patient to determine

    • number, gender of partners
    • sexual practices (anal, oral, vaginal sex)
    • patterns of condom use
    • prior STD testing history, and diagnoses
  • Identify factors affecting patient risk
    • current/past history of unprotected sex
    • intentions for becoming pregnant
    • history of domestic violence
    • history of injection drug use
sample risk assessment questions
Sample Risk AssessmentQuestions
  • 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 STD?
  • What is your experience with shooting up drugs?
  • 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
Assess Personal Perception of Risk
  • Identify factors affecting patient’s personal perception of risk (knowledge, attitudes, beliefs)

Note: if perception of risk is not accurate, counselor assists patient in recognizing risk

  • Consider patient’s level of readiness for change:*
    • Pre-contemplation
    • Contemplation
    • Preparation
    • Action
    • Maintenance
safer goal behavior questions
Safer Goal Behavior Questions
  • How would you like to change that?
  • What would you like to do differently?
  • What might be better for you to do?
client centered counseling
Client Centered Counseling

Risk Behavior


vaginal sex with

new partner

Safer Goal Behavior

Consistent condom

use with this partner

possible goal behaviors for std risk reduction
Possible Goal Behaviors for STD Risk Reduction
  • Reducing # of sexual partners
  • Increase in condom use with main/non-main partners
  • Partner testing
  • Monogamy
  • Abstinence
  • Consideration of any of the above
client centered counseling29
Client Centered Counseling

Risk Behavior

Safer Goal Behavior

Factors that





identify barriers sources of support for change
Identify Barriers/Sources of Support for Change
  • Personal perception of risk
  • Self efficacy related to negotiating safer sex
  • Power and control dynamics in relationships
  • Cultural issues
  • Access to care
  • Significant others
client centered counseling31
Client Centered Counseling

Safer Sex Goal

Risk Behavior



Factors that

influence behavior

Personalized Action Plan




negotiate realistic simple risk reduction steps with patient
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:

  • support efforts previously attempted by patient
  • offer options, not directives
  • remain non-judgmental
personalized action plan questions
Personalized Action Plan Questions
  • How will you go about that?
  • What will you need to do first/next?
  • When will be a good time to try/begin this?
  • What is one thing you could do to begin?
  • Who can you talk to about this for support?
refer to specialized services if needed
Refer to Specialized Services, If Needed
  • Alcohol or drug treatment programs
  • Partner/domestic violence services
  • Partner counseling and referral services
  • Couples counseling
  • Benefits counseling to obtain access to services
taking personal stock
Taking Personal Stock
  • Helping clients change behavior may begin with changing some of our own
    • Recognize our biases and keep them in check
    • Talk less, listen more
    • Encourage step-wise, incremental, realistic changes
    • Avoid “should/shouldn’t”,”I think you…..”

“You need to…..”

    • Be willing to give it a try!