Recognizing the Value of Teaching Sexual History-Taking

Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members. Learning how to take a sexual history with compassion, sensitivity, and thoroughness is a critically important clinical skill for health professions students to learn at all levels of training. Sexual histories provide valuable insight into the health of patients across the age spectrum, particularly regarding their overall sexual health and well-being. Taking a careful sexual history can help to guide discussions with patients about family planning, reproductive health decisions, and clinical considerations associated with pregnancy, including high-risk or unplanned pregnancies. Sexual histories are necessary in assessing sexual dysfunctions and related medical and psychological issues, the potential for sexually transmitted infections, and the presence of sexually related traumas or intimate partner violence. Importantly, patients may present for clinical care with a wide range of health concerns—acute or chronic, local or systemic, minor or life-threatening—due to an underlying health event or problem related to their sexual or reproductive health, sexual activity, exposures, or trauma. Excellence in sexual history-taking is essential to the clinical evaluation and the process of arriving at a proper differential diagnosis. Consequently, what and how we teach sexual history-taking and the efficacy of such teaching warrant very close attention in the medical curriculum. In this issue, Chinn and Hawn1 emphasize the importance of conducting a comprehensive reproductive and sexual history in surgical settings. They argue that doing so provides clinicians with important knowledge that may prevent injury during surgical procedures and help to clarify the impact of surgery on sexual health. For example, taking a careful sexual history may guide a clinician’s decisions regarding therapeutic interventions that may be contraindicated if a patient is or plans to become pregnant or, alternatively, is taking medications that may interfere with the efficacy of oral contraceptives. Chinn and Hawn build on a report2 by Coleman et al, who describe an intervention to improve sexual history-taking by third-year medical students participating in a surgical clerkship. The authors provided an additional didactic session that emphasized the clinical relevance of sexual history-taking when a patient presents with acute right lower abdominal pain. Students who received this additional training were encouraged to take a focused sexual history in appropriate clinical contexts, but many did not do so in a subsequent assessment of students' skills in a relevant standardized patient encounter. For students with and without additional training, the authors identified a positive association between students' attention to the sexual history and their skill in considering salient sexual health-related diagnoses.2 This project reinforces the need for ongoing curricular attention to thorough history-taking. Findings of the study by Coleman et al are helpful both because of the paucity of published empirical work on teaching sexual history-taking3 and also because of the meaningful outcome assessments they employed in their project. Limitations of the work include the use of a single-site cohort design, the potential for confounding, and lack of longer-term follow-up. Sexual history-taking is important in the clinical care of all patients—and especially so in the care of individuals who belong to potentially vulnerable groups. One reason for this observation, tragically, is the prevalence of sexual violence and the common experience of sexual trauma. As just one example, the most recent National Intimate Partner and Sexual Violence Survey4 performed by the Centers for Disease Control and Prevention found that 26.8% of women and 3.8% of men in the United States experience rape or attempted rape in their lifetimes, roughly half before age 18 and most commonly by an acquaintance or family member. High school and college students are a vulnerable group in that they are at heightened risk for sexual assault. Among high school students, for instance, the most recently published Youth Risk Behavior Surveillance System survey5 documents that in 2023, as many as 9% of high school students overall and 17% of LGBTQ+ high school students reported that they had been physically forced to have sexual intercourse.5 Among students beyond high school, 6,457 criminal offenses of rape were reported on college campuses in 2021 to the U.S. Department of Education.6 In a 2019 survey,7 13% of 181,752 university student respondents at 33 universities in the United States reported nonconsensual sexual contact by physical force or by inability to provide consent. These numbers are likely underestimates, as only 1 in 3 instances of sexual assault is formally reported to police.8 Individuals with disabilities are also at elevated risk for sexual assault and major health consequences due to sexual assault. In a systematic review9 of 68 studies with 84 independent samples (n = 12,427 participants overall) published from 1970 to 2018, Amborski et al found that people with disabilities were twice as likely to experience sexual victimization than were persons without disabilities, with individuals with sensory impairment at the greatest risk. People with intellectual disabilities represent approximately 1% of the U.S. population,10 and such individuals experience sexual violence and nonconsensual sexual contact, as documented in multiple studies.11 Intellectual and developmental disabilities may intersect with major mental disorders,12 and women with major mental disorders experience sexually violent acts at a greater rate than do women in comparison groups.13 Serious and disabling mental illnesses affect approximately 5% of adults, and this population experiences high levels of sexual trauma. An early study in the United Kingdom14 found that women with serious mental illness were at substantially greater risk for sexual assault than were age-matched women in the general population and experienced increased risk of suicidality after the assault. Patients with major mental disorders, including schizophrenia-spectrum disorders and bipolar disorders, are more likely to face unplanned pregnancies and sexually transmitted infections when compared with groups without major mental disorders.15,16 Women with major mental disorders also face barriers to adequate reproductive health care.15,16 Persons with mental health disorders constitute around 67% of the adult homeless population globally.17 It is clear that the combination of experiencing housing insecurity and experiencing disability due to mental health disorders greatly elevates risk of sexual trauma. Persons who are sex trafficked are a very vulnerable and underrecognized population. Sex trafficking is one facet of human trafficking where a commercial sex act is induced by force, fraud, or coercion, or in which a person who has not attained 18 years of age is induced to perform a commercial sex act.18 People of any gender can be sex trafficked, and sex-trafficked persons have a very heterogeneous set of cultural and socioeconomic backgrounds. Trafficked persons might not self-identify or self-disclose as such, and clinicians are often ill equipped to recognize signs of human trafficking.19 Therefore, trafficked persons may go unrecognized in health care settings.20 Although there are no reliable estimates on the prevalence of sex trafficking in the United States, according to the Polaris Annual Report of 2023,21 the National Human Trafficking Hotline identified 9,619 situations of trafficking involving 16,999 trafficked persons in 2023 alone, the majority of whom were sex trafficked. Homelessness,22 alcohol abuse,22 and substance use14,22 may be contributing factors to criminal victimization generally, and in the context of sexual victimization, sex-trafficked women carry a greater burden of sexually transmitted infections.23 One component of sexual trauma is reproductive control or reproductive coercion, which is defined as a behavior that interferes with a person’s autonomous decision making regarding reproductive health.24,25 Forms of reproductive control in sex-trafficked settings include birth control sabotage, pressuring into pregnancy, controlling pregnancy outcomes, and forced birth control, including sterilizations.26 Sexual health concerns arise in the care of patients in emergency, ambulatory, and inpatient settings and are relevant to clinical interventions in the context of primary, specialty, and subspecialty care. Carrying out a careful sexual history is one part of comprehensive medical data-gathering in all these settings and contexts of patient care. And, taken together, many, many millions of people are survivors of sexual violence, which has significant health consequences. Unwanted pregnancy can be one such consequence, and the legal constraints on medical intervention in the situation of pregnancy following rape are determined, at the time of this writing, state by state, as of 2022.27 In thinking about the size and impact of this specific issue related to sexual assault, it is estimated that there were 519,981 survivors of completed rapes, with 54,565 rape-related pregnancies, during the 4 to 18 months that abortion bans were in effect in multiple states between July 1, 2022 and January 1, 2024.28 For these reasons, health professions educators increasingly will need to help their clinical trainees learn to take a sexual history and address a wide range of closely related physical and mental health issues while serving patients in a wide range of settings and areas of medicine, and to do so with awareness of ethical and legal expectations and requirements. A tall order, which can best be filled when health professions educators themselves have the knowledge and skills in sexual history-taking that enrich their teaching and can allow them to serve as role models for learners. Best practices in teaching how to take a sexual history compassionately, sensitively, and thoroughly have nevertheless remained underdeveloped in health professions education. One blueprint for teaching sexual history-taking skills29 reflects the consensus of experts’ opinions over multiple years and was published in 2018. The recommended approach features a “spiral curriculum with varied teaching formats,” inclusion of a sexual history “script” taught during the preclinical years of medical training, and longitudinal assessment. It was further recommended that the sexual health curricular content be integrated into “existing clinical interviewing and physical examination courses,” with direct observation of trainees and feedback provided by faculty members.29 This approach has not been widely adopted, perhaps due to already crowded and condensed training curricula in health professions education. Indeed, relatively little and inconsistent curricular attention is given to sexual history-taking, as shown in a recent systematic review30 reporting on 36 studies of interventions in medical and nursing student education. The authors found that interventions were of variable length and content, and few included formal outcomes relevant to clinical competence.30 One other earlier systematic review,3 focused on 11 published randomized controlled and controlled nonrandomized trials, had similar findings and revealed only one high-quality trial on teaching sexual history-taking. In this review, the authors were not able to identify trials that included obstetrics-gynecology residents, despite the relevance of sexual health to this specialty, or that included psychiatry residents, despite the relevance of sexual trauma to this specialty. The observations from these 2 systematic reviews reinforce the question of the adequacy of the skill set of medical and other health professions trainees with respect to sexual history-taking and comprehensive medical history-taking in the evaluation of patients. We suggest that sexual history-taking should be attuned to the individual patient, with attention to their age and stage of development, gender, orientation, behavior, and life experiences. Sexual history-taking, moreover, should be undertaken in a manner that is sensitive to the patient’s personal values, goals, and medical needs. In this process, clinicians should guard against biased or prejudicial attitudes that can interfere with developing a trusting relationship, or lead to discriminatory practices31 that may prevent patients from receiving proper medical attention. At a clinic or system level, services should be available to adequately address a patient’s identified needs. For example, after learning about violence perpetrated against a patient by a sexual partner, services should be aligned to address the associated psychological consequences and, when indicated, to enable safe placement. The United States Preventive Services Task Force32 has published recommendations on screening for intimate partner violence, elder abuse, and abuse of vulnerable adults. The task force concluded that screening for intimate partner violence in women of reproductive age and providing women who screen positive with ongoing support services have a moderate net benefit.32 The task force also concluded that there was not enough evidence to assess the balance of benefits over harms of screening for elder abuse or abuse of vulnerable adults.32 As a second example, meeting the sexual health needs of patients with major mental disorders is best done in collaboration with obstetricians, gynecologists, and family planning specialists who can provide expert counsel,33 and with other programs when indicated, including alcohol and substance use programs, sexually transmitted infection services, or parenting classes. A third example concerns the need to provide comprehensive multidisciplinary programs for persons identified as sex trafficked.34 Case management and access to legal advocacy will be necessary in such circumstances, in addition to appropriate medical services, including psychiatric ones. A trauma-informed approach to sexual history-taking is also necessary, as we have demonstrated, given the tragedy of the common experience of sexual assault in our society. Teaching about the sexual history should educate health professions students about the techniques of trauma-informed care, including providing a safe environment for patients, being trustworthy and transparent, involving peers for support, recognizing that everyone has a role to play in a trauma-informed approach, empowering and respecting patients and their choices, and utilizing the healing value of traditional cultural connections.35 Since patients may feel very fearful about revealing their histories of sexual trauma, the environment should be conducive to enable patients to reveal those histories, and questions should be facilitative without prejudice. To do this well in every circumstance requires the provision of curricula that are effective to that purpose, ongoing practice, and a close attention by clinicians to interview processes. These interview processes should enable patients to be forthcoming about their adversities while overcoming obstacles to obtaining valid sexual trauma histories. Clinicians and clinical trainees may find these aspects of patient care very difficult, especially when encountering situations or life stories that differ greatly from their own experiences and personal beliefs. Teaching should assist learners in overcoming these barriers and should provide guidance and resources to help trainees and clinicians to manage secondary trauma. In addition, having multidisciplinary teams available for referrals for highly complex and traumatized patients (e.g., rape victims, pregnant minors) will greatly assist clinicians to have confidence to screen for a history of, for example, sexual violence or of trafficking, with the knowledge that their patients will receive the requisite support and treatment.36 Sexual history-taking, including the recognition of early pregnancies, is one component of a comprehensive medical evaluation and opens up the possibility of counseling and supportive interventions. Teaching about sexual history-taking entails an understanding of clinical standards of care and the role of state and local legal requirements, including when to engage law enforcement, such as in the case of sexual exploitation of a minor or a disabled or dependent adult. Legal considerations have always played a role in sexual history-taking, and with new requirements that differ state-by-state, these issues should continue to receive attention in health professions curricula. Sexual history-taking is a critical step in assisting patients with a range of sexual health needs that may go undiagnosed or underappreciated for their clinical consequences. We have illustrated the importance of sexual history-taking as one part of thorough medical data-gathering by highlighting examples of vulnerable patient populations for whom attention to sexual health concerns is imperative. And yet, sexual history-taking is vital to the clinical care of every patient. And for this reason, those entrusted with preparing students in the health professions must recognize the value of teaching sexual history-taking, as this skill is fundamental to their students’ ability to address the needs of future patients.