Sexual history taking, 5 Ps, gender-neutral language, MSM/MSW context

Definition / Overview

• Sexual history taking is a foundational clinical skill in general practice that involves systematically gathering information about a patient's sexual behaviours, relationships, and health concerns to identify risks, diagnose conditions, and provide appropriate preventive care.
• The structured approach using the "5 Ps" framework (Partners, Practices, Protection, Past STIs, Prevention of pregnancy) ensures comprehensive assessment while maintaining patient comfort and confidentiality.
• This skill requires cultural competence, use of gender-neutral and gender-affirming language, and awareness of specific contexts including men who have sex with men (MSM), men who have sex with women (MSW), women who have sex with women (WSW), and transgender or gender-diverse individuals.
• In Australia, sexual history taking is guided by resources from the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM), the Royal Australian College of General Practitioners (RACGP), and state-based sexual health services.

Effective sexual history taking serves multiple purposes: screening for sexually transmitted infections (STIs), assessing contraceptive needs, identifying sexual dysfunction, detecting sexual violence or coercion, and providing preventive health interventions including vaccination and pre-exposure prophylaxis (PrEP) for HIV.

Clinical Background

• Sexual health consultation occurs across diverse clinical contexts in Australian general practice.
• Patients may present with symptoms suggestive of STIs, request contraception, seek sexual health screening, or disclose concerns during routine consultations.
• Many patients will not spontaneously discuss sexual health concerns without a direct, normalising invitation from the clinician.
• The epidemiology of STIs in Australia demonstrates ongoing public health challenges.
• Chlamydia remains the most commonly notified STI, with highest rates in young adults aged 15-29 years.
• Gonorrhoea notifications have increased substantially over the past decade, particularly among MSM in urban centres.
• Infectious syphilis has re-emerged as a significant concern, with epidemics in Aboriginal and Torres Strait Islander communities in remote areas and among MSM in metropolitan regions.
• HIV transmission continues predominantly among MSM, though heterosexual transmission accounts for approximately 20% of new diagnoses.
• Clinical Pearl: Aboriginal and Torres Strait Islander peoples experience disproportionate rates of STIs and blood-borne viruses, requiring culturally appropriate screening approaches.
• NACCHO-affiliated Aboriginal Community Controlled Health Organisations provide culturally safe sexual health services.
• The concept of Gillick competence, adapted from UK common law, operates across Australian states and territories.
• A young person under 16 years may consent to medical treatment, including sexual health care, if they demonstrate sufficient understanding and maturity to comprehend the proposed treatment, its implications, and alternatives.
• This principle enables adolescents to access confidential sexual health services without parental consent, though state-specific legislation varies slightly (NSW: s49 Minors (Property and Contracts) Act 1970; Vic: s25 Medical Treatment Planning and Decisions Act 2016; Qld: common law applies).
• Red Flag: Mandatory reporting obligations apply when sexual activity involves a child under specific ages (varies by state: 10-16 years) or when there are reasonable grounds to suspect child sexual abuse.
• Balance confidentiality with legal obligations, consulting senior colleagues or state child protection services when uncertain.
• MSM face specific sexual health risks including higher rates of HIV, syphilis, gonorrhoea (including pharyngeal and rectal), hepatitis C (via sexual transmission during condomless anal sex with mucosal trauma), and lymphogranuloma venereum (LGV).
• Barriers to care include stigma, discrimination, previous negative healthcare experiences, and assumptions of heterosexuality by clinicians.
• Creating explicitly safe and affirming environments is essential for disclosure and ongoing care.

Clinical Features

The 5 Ps Framework

The 5 Ps provide a systematic structure for comprehensive sexual history:

Gender-Neutral and Gender-Affirming Language

Avoid assumptions about gender identity, sexual orientation, or anatomical configuration. Opening questions should be inclusive and non-prescriptive:

"Do you have sex with men, women, both, or people of other genders?" "What pronouns do you use?" "Does your current gender match the sex you were assigned at birth?" "Which body parts are you concerned about today?" (for symptom assessment) "Do you have a cervix/prostate?" (for screening discussions)

• Terminology should match the patient's own language.
• Some patients use identity terms (gay, lesbian, bisexual, queer, pansexual), while others describe behaviour without identity labels.
• MSM includes gay-identified men, bisexual men, and men who have sex with men but do not identify as gay or bisexual, recognising that behaviour rather than identity determines STI risk.
• Clinical Pearl: The term "regular partner" is more inclusive than "husband/wife" or "boyfriend/girlfriend" and does not assume monogamy or relationship structure.
• Ask about each partner separately if multiple partners are disclosed.

MSM-Specific Considerations

When a patient discloses male partners or identifies as MSM, extend the history to include:

• Specific sites of exposure: pharynx, rectum, urethra, skin (relevant for gonorrhoea, chlamydia, syphilis testing)
• HIV status and testing frequency
• PrEP use: current regimen, adherence, prescriber, STI screening schedule (ASHM recommends 3-monthly STI screening for MSM on PrEP)
• Hepatitis A and B vaccination status
• Use of recreational drugs in sexual contexts (chemsex), including methamphetamine, GHB/GBL, mephedrone
• Knowledge of partners' HIV status (serosorting practices)
• Use of sexual networking apps or websites

MSM who are HIV-positive require specific assessment:

• Current antiretroviral therapy and adherence
• Most recent HIV viral load and CD4 count
• Knowledge of U=U (undetectable = untransmittable)
• Disclosure practices with partners

Creating Safe Disclosure Environments

Environmental and communication strategies that facilitate disclosure:

1. Display visible cues of inclusion (rainbow flags, gender-neutral bathroom signs, inclusive patient information)
2. Normalise sexual history as routine: "I ask all my patients about their sexual health"
3. Ensure confidentiality and explain its limits explicitly
4. Use open-ended, non-judgmental questions
5. Allow silence for patients to formulate responses
6. Maintain neutral facial expressions and body language
7. Avoid medical jargon; use clear, accessible language
8. Acknowledge discomfort: "Some people find these questions difficult. Take your time"

Investigations

Sexual health screening investigations are guided by anatomical sites of exposure, timing since exposure, and patient-specific risk factors.

General STI Screening (Asymptomatic Patients)

Standard first-pass urine (males): first-void urine for Chlamydia trachomatis and Neisseria gonorrhoeae nucleic acid amplification testing (NAAT)

• Vaginal swab (females): self-collected or clinician-collected for chlamydia and gonorrhoea NAAT.
• Cervical samples are no longer required for screening.

Serology: HIV, syphilis, hepatitis B surface antigen (HBsAg), hepatitis B core antibody (HBcAb), hepatitis C antibody (HCV Ab)

MSM-Specific Screening

ASHM guidelines recommend comprehensive three-site testing for sexually active MSM:

• Pharyngeal swab: gonorrhoea NAAT (chlamyria pharyngeal testing no longer recommended due to commensal species cross-reactivity)
• Rectal swab: gonorrhoea and chlamydia NAAT (self-collected is acceptable and preferred by many patients)
• First-pass urine: gonorrhoea and chlamydia NAAT
• Serology: HIV, syphilis, HBsAg, HBcAb, HCV Ab (if HIV-positive, 3-monthly HCV screening recommended)
• Screening frequency for MSM: 3-12 monthly depending on risk factors.
• ASHM recommends 3-monthly screening for MSM with multiple partners, inconsistent condom use, or PrEP use.

Symptomatic Presentations

Window Periods and Repeat Testing

Management

General Principles

Sexual health management extends beyond treating diagnosed infections to include partner notification, vaccination, prevention counselling, and psychosocial support.

• Partner notification: Discuss with all patients diagnosed with STIs.
• Options include patient-led notification, provider-assisted anonymous notification (via sexual health services), or expedited partner therapy where legislatively permitted.
• Contact tracing periods vary by infection (chlamydia: 6 months prior; gonorrhoea: 2 months prior; infectious syphilis: 12 months prior).

STI Treatment (First-Line Regimens per eTG)

• Red Flag: Gonococcal treatment failure is increasing in Australia.
• Test of cure is now recommended 7-14 days after treatment for pharyngeal gonorrhoea and 14 days for all other sites.
• Consider antimicrobial resistance if symptoms persist.

HIV Prevention

• Pre-exposure prophylaxis (PrEP): Tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) 300/200mg daily or event-based dosing (2-1-1 schedule).
• Indicated for MSM with condomless anal sex, serodiscordant couples, people who inject drugs.
• Prescribers must complete ASHM PrEP training.
• MBS-subsidised under s100 prescribing from March 2022.
• Requires 3-monthly STI screening, renal function monitoring (creatinine, eGFR), and HIV testing before each prescription.
• Post-exposure prophylaxis (PEP): Commenced within 72 hours (ideally <24 hours) of high-risk exposure.
• Standard regimen: TDF/FTC plus raltegravir or dolutegravir for 28 days.
• Available through emergency departments, sexual health clinics, and trained GPs.
• PBS-subsidised.
• Follow-up HIV testing at 6 and 12 weeks.

Vaccination

Counselling and Prevention

Discuss risk reduction strategies without prescribing behaviour. Harm reduction principles apply:

• Condom use and correct application
• Reducing partner numbers
• Regular STI testing
• PrEP for HIV prevention
• Treatment as prevention (U=U messaging for HIV-positive individuals)
• Safe chemsex practices (clean equipment, avoid sharing, hydration, consent capacity)
• Recognising and exiting coercive relationships

Red Flags

• Red Flag: Adolescent under 16 disclosing sexual relationship with adult >2 years older.
• Assess for coercion, exploitation, or abuse.
• Familiarise with state-specific age of consent laws and mandatory reporting thresholds.
• NSW: must report if child under 16 and partner >18, or reasonable grounds for abuse.
• Victoria: must report sexual abuse of child under 16 to Child Protection or Victoria Police.
• Red Flag: Recurrent STIs despite reported treatment adherence and reduced risk behaviour.
• Consider antimicrobial resistance (gonorrhoea), reinfection from untreated partners, sexual violence or coercion preventing partner disclosure, or chemsex-related risk amnesia.
• Red Flag: Patient requesting sexual health screening but declining blood tests.
• May indicate previous HIV-positive diagnosis not disclosed, fear of positive result, or needle phobia.
• Explore gently: "Some people worry about particular tests.
• Is there anything specific you're concerned about?"
• Red Flag: Inconsistency between reported low-risk behaviour and recurrent STIs or complex infection patterns (e.g. rectal gonorrhoea in person reporting no anal sex).
• May indicate sexual assault, undisclosed sexual practices due to shame, or coerced sex work.
• Create space for disclosure without pressure.
• Red Flag: MSM with first episode of infectious syphilis and negative HIV test requires close follow-up.
• Syphilis is a strong marker for HIV acquisition risk.
• Consider PrEP discussion and offer repeat HIV testing at 6 and 12 weeks.

Australian Context

• Sexual health service delivery in Australia involves tiered care across general practice, Aboriginal Community Controlled Health Organisations, state-based sexual health clinics, and hospital-based services.
• Many metropolitan centres have specialised sexual health clinics offering walk-in services, partner notification, and complex case management (Sydney Sexual Health Centre, Melbourne Sexual Health Centre, Clinic 275 Brisbane, Adelaide Sexual Health Centre).
• ASHM provides national clinical guidelines, PrEP prescriber training, and an annual sexual health conference.
• The ASHM website hosts point-of-care resources including testing guidelines, treatment protocols, and cultural competency training modules specifically addressing MSM, Aboriginal and Torres Strait Islander peoples, and culturally and linguistically diverse (CALD) communities.
• Clinical Pearl: Pathology request forms should specify anatomical sites for NAAT testing.
• Generic "STI screen" requests may default to first-pass urine only, missing pharyngeal or rectal infections in MSM.
• Write explicit requests: "pharyngeal swab for gonorrhoea", "rectal swab for chlamydia and gonorrhoea".
• Telehealth sexual health consultations expanded during COVID-19 and remain MBS-subsidised.
• Self-collection kits for STI screening can be posted to patients, particularly valuable for rural and remote patients.
• However, limitations include inability to perform genital examination, collect blood for serology, or administer intramuscular treatments.
• Remote Aboriginal and Torres Strait Islander communities face ongoing infectious syphilis outbreaks, particularly across NT, northern WA, and SA.
• Enhanced screening programs operate through primary health networks and NACCHO affiliates.
• Point-of-care syphilis and HIV testing enables same-day treatment in contexts where follow-up may be challenging.
• State-based legislation affects sexual health service provision.
• NSW allows pharmacist prescribing of PrEP under protocol with GP oversight.
• Victoria funds Rainbow Health Victoria for LGBTIQ+ health professional training.
• Queensland's Betterlife program provides free STI testing and treatment for young people under 30 through participating GPs.

Longer GP consultations (e.g. Level C, item 36, at least 20 minutes; Level D, item 44, at least 40 minutes) allow an extended sexual health discussion.

Key Points

• High-Yield: The 5 Ps framework (Partners, Practices, Protection, Past STIs, Prevention of pregnancy) ensures systematic, comprehensive sexual history taking without assuming patient gender identity, sexual orientation, or practices.
• High-Yield: Use gender-neutral language universally ("Do you have sex with men, women, both, or people of other genders?"). Ask about specific anatomical exposures rather than assuming based on patient gender presentation.
• High-Yield: MSM require three-site testing (pharyngeal, rectal, urine) for gonorrhoea and chlamydia. Pharyngeal chlamydia testing is no longer recommended due to false positives. ASHM recommends 3-monthly STI screening for MSM with ongoing risk.
• Gillick competence allows adolescents under 16 to consent to confidential sexual health care if they demonstrate sufficient maturity, though mandatory reporting obligations apply when abuse or exploitation is suspected (varies by state).
• PrEP requires 3-monthly STI screening, HIV testing, and renal function monitoring. Prescribers must complete ASHM training. MBS-subsidised under s100 prescribing since March 2022. Event-based dosing (2-1-1) is an alternative to daily dosing for MSM.
• Partner notification is essential for STI control. Tracing periods vary: chlamydia 6 months, gonorrhoea 2 months, infectious syphilis 12 months. Sexual health services offer anonymous partner notification if patient-led notification is unsuccessful.
• Normalise sexual history as routine care ("I ask all my patients about sexual health") and create safe environments through visible inclusion cues, explicit confidentiality statements, and non-judgmental communication. Display awareness of ASHM resources and LGBTIQ+ health competencies.
• Red Flag: Recurrent STIs, discordance between reported behaviour and infection patterns, or adolescent relationships with significant age gaps warrant exploration for coercion, untreated partners, antimicrobial resistance, or sexual violence.