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EDUCATION
REVIEW
Best Practices in North American Pre-Clinical Medical Education in
Sexual History Taking: Consensus From the Summits in Medical
Education in Sexual Health
Elizabeth S. Rubin, MD,
1
Jordan Rullo, PhD,
2,3
Perry Tsai, PhD,
4
Shannon Criniti, PhD, MPH,
5
Joycelyn Elders, MD,
6
Jacqueline M. Thielen, MD,
3
and Sharon J. Parish, MD
7
ABSTRACT
Introduction: This article discusses a blueprint for a sexual health communication curriculum to facilitate
undergraduate medical student acquisition of sexual history taking skills and includes recommendations for
important elements of a thorough sexual history script for undergraduate medical students.
Aim: To outline the fundamentals, objectives, content, timing, and teaching methods of a gold standard
curriculum in sexual health communication.
Methods: Consensus expert opinion was documented at the 2012, 2014, and 2016 Summits in Medical
Education in Sexual Health. Additionally, the existing literature was reviewed regarding undergraduate medical
education in sexual health.
Main Outcome Measures: This article reports expert opinion and a review of the literature on the development
of a sexual history taking curriculum.
Results: First-year curricula should be focused on acquiring satisfactory basic sexual history taking
skills, including both assessment of sexual risk via the 5 Ps (partners, practices, protection from sexually
transmitted infections, past history of sexually transmitted infections, and prevention of pregnancy) as well
as assessment of sexual wellness—described here as a sixth P (plus), which encompasses the assessment of
trauma, violence, sexual satisfaction, sexual health concerns/problems, and support for gender identity and
sexual orientation. Second-year curricula should be focused on incorporating improved clinical reasoning,
emphasizing sexual history taking for diverse populations and practices, and including the impact of
illness on sexual health. Teaching methods must include varied formats. Evaluation may be best as a
formative objective structured clinical examination in the first year and summative in the second year.
Barriers for curriculum development may be reduced by identifying faculty champions of sexual health/
medicine.
Clinical Implications: Medical students will improve their skills in sexual history taking, which will ultimately
impact patient satisfaction and clinical outcomes. Future research is needed to validate this proposed curriculum
and assess the impact on clinical skills.
Strengths & Limitations: This article assimilates expert consensus and existing clinical guidelines to
provide a novel structured approach to curriculum development in sexual health interviewing in the
pre-clinical years.
Conclusion: The blueprint for developing sexual history taking skills includes a spiral curriculum with varied
teaching formats, incorporation of a sexual history script that incorporates inquiry about sexual wellness, and
longitudinal assessment across the pre-clinical years. Ideally, sexual health communication content should be
Received March 9, 2018. Accepted August 20, 2018.
1
Department of Obstetrics and Gynecology, Perelman School of Medicine,
University of Pennsylvania, Philadelphia, PA, USA;
2
Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN,
USA;
3
Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA;
4
University of North Carolina at Chapel Hill School of Medicine, Chapel Hill,
NC, USA;
5
AccessMatters, Philadelphia, PA, Drexel University, Philadelphia, PA, USA;
6
Fay W. Boozman College of Public Health, University of Arkansas for
Medical Sciences, Little Rock, AR, USA;
7
Department of Medicine, Department of Psychiatry, Weill Cornell Medical
College, New York, NY, USA
Copyright ª2018, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jsxm.2018.08.008
1414 J Sex Med 2018;15:1414e1425
incorporated into existing clinical interviewing and physical examination courses. Rubin ES, Rullo J, Tsai P,
et al. Best Practices in North American Pre-Clinical Medical Education in Sexual History Taking:
Consensus From the Summits in Medical Education in Sexual Health. J Sex Med 2018;15:1414e1425.
Copyright 2018, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Objective Structured Clinical Exam; Sex Education; Medical Education; Pre-Clinical Education;
Sexual Health; Sexual History
INTRODUCTION
Sexual problems and sexually transmitted infections (STI) are
widely prevalent, and a comprehensive sexual history is an
essential component in the identification and treatment of these
problems.
1e5
Thus, conducting a sexual history is a well-
established fundamental element of the clinical interview that
is strongly recommended by the World Health Organization.
6e8
Given that most patients do not speak with their physicians
about sexual health concerns,
9
routine sexual history screening
improves detection without placing the responsibility on the
patient to bring up potentially uncomfortable topics.
6,10,11
Unfortunately, the majority of health care providers, ranging
from 60e100%, do not routinely ask patients about their sexual
history.
12e18
This oversight may leave patients feeling dismissed,
ignoring treatable sexual problems, or at risk of contracting/
transmitting STI.
11,19e24
As such, acquisition of comprehensive and fluid sexual history
taking skills is essential for undergraduate medical students. The
NIH stated that health care providers should have courses in
effective sexual history taking; and the International Society for
Sexual Medicine curriculum in international undergraduate
sexual health education recommended sexual history taking,
comfort with sexual language, and general communication skills
as specific skills that should be acquired during undergraduate
medical education.
25,26
Sexual history taking education, how-
ever, remains inconsistent, limited, or non-existent in the ma-
jority of North American medical schools,
27,28
and insufficient
training remains a prevalent barrier to adequate sexual history
taking.
29e33
In all, 44% of U.S. medical schools may have no
formal curriculum in sexual health.
28
Though the majority of medical students believe sexual history
taking is an important skill for future practice, over half of them
do not report adequate training in this area.
31,34e36
After grad-
uation, many resident physicians remain uncomfortable
addressing topics of sexual health and sexuality with
patients.
36e39
Sexual health education is effective in increasing
students’, residents’, and health care providers’comfort and
confidence in taking a sexual history.
32,40e43
When students
perceive they have received adequate sexuality education, they are
more likely to be comfortable addressing patients’sexual
health.
31
Undergraduate medical school curricula for the education and
evaluation of students’sexual history skills are widely vari-
able,
27,32
in part due to lack of consensus among schools
regarding standardized goals, objectives, and curricula.
7,27,44e46
Though 128 medical colleges in North America report teach-
ing students to ask patients, "Do you have sex with men, women,
or both," curricula typically remain largely focused on risk
stratification for STI and pregnancy prevention.
46,47
The ma-
jority of programs do not include clinical training on sexual
problems and dysfunction, and sexual history scripts provided to
students rarely include discussion of sexual problems.
48e51
Though efforts have been made to improve standardization in
medical education in sexual health and sexuality,
7,35,44,52,53
the
vast majority (92%) of U.S. schools with a sexual health cur-
riculum have developed their own curriculum rather than basing
the curriculum on established standards.
28
While individual
programs may have found site-specific success in teaching sexual
history taking, there has not yet been described a prescriptive
model detailing best practices for teaching and evaluating student
acquisition of sexual history taking skills.
7,51,52,54,55
The First Summit on Medical Education in Sexual Health,
organized in 2012 and hosted by the Program in Human
Sexuality, Department of Family Medicine and Community
Health, University of Minnesota Medical School, Minneapolis,
MN, called for national standards for sexual health education.
52
The Second and Third Summit on Medical Education in Sexual
Health, 2014 and 2016, were held to create recommendations
for improvement in specific areas of sexual health curricula,
including sexual history taking. “Arguably, sexual history taking
is one of the most essential skills to addressing sexual health with
patients,”according to experts of the summit.
45
Bayer et al
53
in
2017 identified consensus from the first and second summits on
proper content for sexuality in medical curricula and outlined 20
sexual health competencies for undergraduate medical education
in North America. Education in effective sexual history taking is
essential to attaining the competencies outlined in the accredi-
tation domains of patient care, interpersonal and communication
skills, and professionalism.
53
In this report we identify the current deficits in sexual history
taking education and describe a model pre-clinical curriculum for
teaching sexual health communication skills that can be incor-
porated into existing clinical interviewing and physical exami-
nation courses. We address methods for educating students on
sexual history taking, explaining diagnosis and treatment, and
counseling patients on sexual health problems. We articulate how
a spiral curriculum, one that circles back to these topics
throughout the pre-clinical years, can provide this training.
56,57
J Sex Med 2018;15:1414e1425
Medical Education in Sexual History Taking 1415
Further, in accordance with the consensus from these summits,
and unlike most previous sexual history tool kits that emphasize
sexual risk assessment and stratification,
48,49,58
this curriculum
also focuses on sexual problem screening.
52
While this is an ideal
framework and select elements will be more critical than others,
our hope is that programs can find site-specific ways to include
elements of the curriculum described.
METHODS
The Subcommittee on Sexual History Taking Education at
the Summit on Medical Education in Sexual Health consisted of
members with substantial research and clinical experience in
teaching and assessing sexual health communication skills. This
multidisciplinary group included multiple academic faculty and
resident physicians with specific expertise in medical education
and in sexual medicine spanning internal medicine, psychiatry,
and gynecology. This group also included representation from a
sex therapist, sex educator, and a nationally recognized leader in
public health. Participants extensively discussed both ideal and
critical elements of a comprehensive education in sexual history
taking at the second and third summits until consensus was
reached. Subsequently, a narrative literature review was per-
formed. The literature review involved a comprehensive English-
language search of several databases from 2006 to 2017, which
included MEDLINE In-Process and Other Non-Indexed Cita-
tions and Ovid MEDLINE, Ovid PsycINFO, and Ovid
Cochrane Database of Systematic Reviews. Key words included
“sexual health history taking,”“sexual history taking,”“sexuality
history,”“sex history,”“sexual risk assessment,”“sexual problem
assessment,”and “medical history taking”combined with
“reproductive health”or “sexual behavior.”Articles were selected
for inclusion based on authors’collective expertise and were
organized and consolidated by the first, second, and senior au-
thors. Co-authors reviewed and revised this document for
consensus. The curriculum detailed below is developed from
those discussions and literature review.
OVERVIEW OF CURRICULUM FUNDAMENTALS
Undergraduate medical schools should strive to provide stu-
dents with a longitudinal education in sexual history taking and
sexual health communication skills within a broader curriculum
in communication skills.
27
A spiral curriculum, one that revisits
the same topics repeatedly with increasing level-appropriate
complexity, can be utilized to this end.
56,57
At each stage of
learning, students should meet specific objectives and be evalu-
ated by standards consistent with their level of development.
Though here we have delineated these recommendations as a
traditional first and second year of pre-clinical education, some
programs have modified their curricula such that there is no
longer a distinction between first and second academic years or
such that there are no longer distinct pre-clinical or clinical
years. Non-traditional curricula wishing to incorporate these
recommendations may benefit from identifying when students
are first taught communication skills and when these skills are
reinforced.
Core communication skills that students should learn in the
pre-clinical years are to take a patient-centered sexual history,
build rapport with patients, express empathy, and utilize coun-
seling techniques for a sexual problem.
7,59
Objectives specificto
sexual history taking during pre-clinical years are outlined in
Table 1.
27,45
The teaching methods that should be implemented
include a combination of didactics, role play, and skills practice
with simulated patients (SPs) as a variety of learning modalities is
recommended to maximize adult learning.
7,46
General commu-
nication skills, sexual history taking skills, and these teaching
methods are all widely accepted educational principals.
7,46
This article does not address where and how to teach sexual
health content such as anatomy and physiology of sexual
response cycle, human reproduction, STI, contraceptive
methods, or specific treatment of sexual problems. Recom-
mended objectives for an entire sexual medicine curriculum can
be found in another summit consensus article by Bayer et al
53
in
2017. Additionally, given that the summits focused on North
American medical schools, these recommendations are written
for a North American curriculum. However, many of the prin-
ciples outlined here can be utilized for medical schools interna-
tionally. International recommendations are outlined in the 2
consensus reports on education from the International Consul-
tation in Sexual Medicine by Shindel et al
7
in 2016 and
Eardley et al
60
2017.
FIRST-YEAR CONTENT
Fundamental to sexual health communication skills is the
patient-centered sexual history. Students should learn sexual
history taking skills in the context of a comprehensive sexual
health curriculum that addresses attitudes, knowledge, and
skills.
7,11,27,45,46,53
Basic Sexual History Interview
A primary education in sexual history taking must include
appropriate questions and how to phrase these questions so as to
be direct but also sensitive. This is best achieved by providing
students with a sexual history script that includes questions about
sexual problems or concerns.Students report that having a
Table 1. Pre-clinical objectives
1. Understand importance of discussing sexual health with patients
2. Demonstrate basic skills of sexual health communication
3. Explain key questions/topics for a sexual history
4. Practice taking a sexual history with peers
5. Include elements of counseling and education into patient encounters
6. Identify follow-up questions to specific sexual health concerns
7. Conduct personal reflection on sexual history taking and comfort with
discussing sexual health topics with patients
J Sex Med 2018;15:1414e1425
1416 Rubin et al
written script improves ease of learning sexual history taking
skills.
61
Therefore, early during their first year, students should
be given a sexual history script on which to model their in-
terviews. Currently, most sexual history scripts focus entirely on
sexual risk taking. Arguably the most common sexual history
script is the Centers for Disease Control and Prevention (CDC)
5 Ps (partners, practices, protection from STIs, past history of
STIs, and prevention of pregnancy).
58,59
This is a helpful
mnemonic that outlines the important elements of a sexual risk
assessment and can incorporate an inclusive sexual orientation
and gender identity history within this framework. A thorough
sexual history, however, also needs to include an assessment of
sexual wellness: a sixth P (plus) (Figure 1). The Summit on
Medical Education in Sexual Health recommends that the “plus”
should encompass an assessment of trauma, violence, sexual
satisfaction, sexual health concerns/problems, and support for
gender identity and sexual orientation (Table 2). Many of these
topics are overlooked in sexual history taking education, perhaps
because they may be considered more challenging to address.
7
Recently, the National Coalition for Sexual Health (NCSH)
developed a guide for primary care providers to address the sexual
health of their patients.
62
This guide is an excellent tool for
undergraduate medical education. It includes the 5 Ps, a list of
essential sexual health questions to ask at least once annually, and
questions relevant to adults vs adolescents. Essential questions to
ask regarding the sixth P (plus), listed in Table 2, are an
important extension of this NCSH guide.
Setting
First-year medical students rarely have experience discussing
sensitive issues, and thus time should be spent outlining the
setting for patient discussions about sex or sexuality. Students
should be explicitly taught verbal and non-verbal elements of
creating a positive sexual health discussion setting, outlined in
Table 3.
6,59,63
Additionally, time should be devoted to discussing
the use of open-ended vs closed-ended questions.
Transition and Timing
Students should be supplied with techniques for transitioning
to the discussion of sexual health, including ideal transition
statements that utilize asking patient permission to discuss sexual
health, normalizing sexual health questions, and validation of
patient concerns. The NCSH guide suggests the following
transition statement, “I’m going to ask you a few questions about
your sexual health. Since sexual health is very important to
overall health, I ask all my patients these questions. Before I
begin, do you have any questions or sexual concerns you’d like to
discuss?”
62
Students should learn that the sexual history needs to
fit logically into the flow of questions, following medical history,
social history, or urologic/gynecologic review of systems.
6
When
applicable to the patient, students may want to link sexual his-
tory questions to questions about menstrual cycles, birth control,
menopausal status, or urinary concerns. In learning about tran-
sition and timing, students will also begin to discover which
elements of a sexual history are most important for different
clinical encounters.
FIRST-YEAR TEACHING METHODS
Varied teaching methods/formats will more effectively reach
students with different learning styles.
7,35,46
Recommended
learning strategies for an entire sexual medicine curriculum are
outlined in Shindel et al
7
in 2016. The core elements and
teaching methods/formats of a first-year curriculum in sexual
health communication skills are outlined in Table 4.
Student Self-Preparation
Directly prior to the initiation of the sexual health interview
curriculum, students should be referred to appropriate educa-
tional materials. Self-preparation is critical to student founda-
tional learning of not only the questions to ask, but the elements
of the setting as described in Table 2. In addition to receiving a
sexual history script, students should be assigned homework of
key articles introducing students to the fundamentals of taking a
sexual history. “Standard Operating Procedure for Taking a
Sexual History,”“The Proactive Sexual History,”and the CDC
“A Guide to Taking a Sexual History”are easily accessible in-
troductions, the last of which reviews the 5 Ps.
6,29,58
Students
should also review a video demonstrating a sexual history role
play. Medical schools may wish to purchase a video for use or
create their own school-specific video. The Association of
American Medical Colleges (AAMC) and others have developed
Figure 1. US Centers for Disease Control and Prevention (CDC) 5 Ps and the sixth P (plus). Infographic showing the categories of sexual
history topics clinicians should cover during a sexual health interview. SOGI ¼sexual orientation/gender identity; STI ¼sexually transmitted
infections. Adapted with permission from the CDC.
J Sex Med 2018;15:1414e1425
Medical Education in Sexual History Taking 1417
a series of free online videos on sexual history taking
45
(Appendix).
Didactics
Although not as effective at teaching skills and promoting self-
reflection as interactive modalities,
32
large group lectures remain
the dominant paradigm in medical school education.
50
In a
sexual health communication curriculum, lectures can be used to
introduce sexual health questions and effective communication
skills and to demonstrate an example of an effective, standardized
sexual history.
32,39,40,43,46
This should be made possible via
video or a live role-play demonstration, as observing an interview
has been found to improve interviewing skills.
64
An instructor
who has significant experience in sexual health communication,
ideally within the field of sexual medicine, should be identified
for this demonstration.
11
Although this demonstration should
utilize the standardized script, students may also benefit from an
additional, more advanced demonstration. AAMC has developed
a free modifiable sexual history taking lecture located online at
MedEdPORTAL.
65
Role Play
Role play, that is, taking on scripted "parts" and practicing a
physician-patient encounter, has been found to be an effective
teaching modality for teaching sexual health communica-
tion.
11,40,55,66,67
This is the first-year students’opportunity to
practice their recitation of sexual history questions as well as the
body language critical to a comfortable encounter. Multiple
opportunities should be presented to first-year students to
practice their sexual history taking skills. Initially students should
practice with peers, with peer and faculty feedback. Programs
should ensure that they provide adequately developed role-play
characters such that the students do not have to draw from
their own personal experience.
SP/Standardized Patients
It may be beneficial for students to have at least 1 encounter
with a SP designed specifically for the purpose of practicing
sexual history with immediate SP or faculty feedback.
46,68
SP
education has been found to be effective in reducing student
anxiety and improving interview performance.
69
However, the
benefits of utilizing a SP appear to be comparable to those of peer
role play.
70e72
Ultimately, the educational benefitmaybe
determined more by the quality of feedback received, rather than
the individual giving that feedback.
28
Yet, unlike peer role play,
SP cases have the advantage of including a variety of ages, sexual
orientations, and gender identities, which enhances student
Table 3. Approach to creating a positive sexual health interview
setting for students
1. Reassure patient of privacy, and explain confidentiality (including who
has access to personal information via electronic medical records)
2. Make efforts to ensure patient trust, comfort, and openness
3. Utilize empathy and build rapport
4. Use open body language and appropriate eye contact
5. Be aware of patient’s cultural background
6. Avoid assumptions about sexual orientation, gender identity,
monogamy, sexual activities, or age-related practices
7. Use simple, direct language within your comfort zone
8. Avoid unnecessary interruptions while utilizing gentle redirection
9. Disengage from electronic medical record, turn away from computer,
avoid typing
Table 2. "Plus"—assessment of sexual wellness
Trauma/violence
Do you have a history of unwanted sexual experiences? [If patient is confused] Have you ever been forced or coerced to have sex/sexual activity against
your will, either as a child or as an adult?
o If yes, is there anything about that experience that impacts your current sexuality?
o If yes, is there anything about that experience that makes seeing a health care provider or having a physical examination (if applicable) difficult?
If so, I’d like to hear about this so we can work together more easily.
Support for sexual orientation/gender identity
Do you feel you are getting support and acceptance of your sexual orientation/gender identity from your family and friends?
Are you experiencing any harassment or violence—at home, at work, or in your community—due to your sexual orientation or gender identity?
Sexual concerns/problems
Are you having any concerns with your sexual functioning or your interest in sexual activity?
Do you have decreased or increased interest in sex?
Do you have difficulty becoming sexually aroused? Becoming lubricated/developing an erection?
What about maintaining lubrication or arousal/maintaining an erection?
Do you have difficulty having an orgasm, orgasming too soon, or not soon enough?
Is sexual activity painful?
o If yes, what type of sexual activity is painful? Where is the pain
Are you having any sexual relationship difficulties? Such as discrepancy between your and your partner’s interest in sex, or your partner is having sex
difficulties?
Sexual distress/satisfaction
On a scale from 1e10, with 10 being the greatest impact, how much impact has this problem had on your life? How distressing are these symptoms to
you?
On a scale from 1e10, with 10 being the greatest satisfaction, how satisfied are you with your sexual health? Sexual relationship?
J Sex Med 2018;15:1414e1425
1418 Rubin et al
comfort in discussing sexual health with diverse patients.
51
Due
to the logistical and financial expense of securing SPs, some
programs may need to include sexual history taking SP en-
counters within other pre-existing SP experiences. All programs
should strive to provide at least 1 opportunity for students to
practice incorporating a sexual history into a complete patient
history with a SP.
Discussion Group and Self-Reflection
Many students have discomfort when discussing sexual health
or taking sexual histories,
73,74
and it is important to normalize
these feelings.
11,27,75
This discomfort is multifactorial and in-
cludes embarrassment, cultural differences, inadequate knowl-
edge base, anxiety around personal sexual experience, and
concerns about perception or development of sexual feelings
toward a patient.
7,26,31,73
While some programs might choose to
isolate this topic for discussion, others may choose to incorporate
it as part of a larger discussion group on a potpourri of sensitive
issues. Small group settings have been found to be effective in
improving communication skills in medical students.
9
Students
can provide each other with peer-to-peer strategies while high-
lighting the importance of working through the discomfort to
optimize patient care. Ideally this discussion group should be
facilitated by trained and experienced leaders.
76
This may also be
an avenue to explicitly discuss the hidden curriculum: while
students may not see their preceptors taking sexual histories, this
should not imply that they themselves should not.
11
FIRST-YEAR EVALUATION METHODS
First-year student evaluations should be formative rather than
summative based on faculty-observed SP encounters or video
review.
7,77
Given the wide prevalence of smartphones, tablets,
and laptop computers with video capabilities, video review is
now a logistically and financially viable evaluation method.
78e80
Students should have an opportunity to film themselves taking a
sexual history with a peer or SP, either in isolation or in
conjunction with a complete patient history, for self- or faculty
review. Review can take the form of a written self-reflection,
written feedback from a faculty member, or in-person self-
reflection, and feedback with a faculty member.
Many existing clinical interview courses include a year-end
objective structured clinical examination (OSCE) on history
taking. Sexual history should be a part of this clinical inter-
viewing OSCE. Failure to include sexual history implies that the
sexual history is not as important as other elements of the clinical
interview and misses a valuable opportunity for evaluation.
Recommended student evaluation methods are outlined in
Table 4.
SECOND-YEAR CONTENT
Second-year students should review and expand upon the
basics of sexual health communication by learning to incorporate
advanced interviewing skills and clinical decision making. In a
traditional curriculum with distinct first and second years, edu-
cation on sexual health communication may be separated by over
12 months. In that setting, programs should review the basics of
sexual history taking in year 2. This should be rapidly paced and
include student self-review of the sexual history example video
and a provided sexual history script. Core elements and teaching
methods for a second-year curriculum are outlined in Table 5.
The sections that follow more specifically discuss the advanced
sexual health communication skills that should be addressed in
pre-clinical education. These skills represent the consensus of the
authors and are based on expert opinion.
7,46,52
These advanced
interviewing skills include clinical reasoning and purpose-driven
questioning, questions for specific populations/diversity of
practices, sexual problem-based history, sexual health counseling,
and illness-related sexual health interviewing.
Table 5. Core elements and teaching methods for a second-year
curriculum
Self-preparation: Review of first-year material (video and script)
Self-preparation: Video demonstrations of advanced sexual history role
play
Didactics: Advanced sexual communication skills
Didactics: Advanced sexual history with counseling role play
demonstration
Didactics: Inclusion of sexual history items in existing didactics
Role play: Advanced sexual history taking with feedback from faculty; a
scenario with a LGBTQ patient with a sexual problem or illness-related
sexual concern
Role play: Sexual history taking during focused history in general
simulated patient scenarios
Role play: Sexual history taking during complete history in general
simulated patient scenarios
Summative evaluation: Inclusion of sexual history in midterm and year
end objective structured clinical exam or group objective structured
clinical exam
LGBTQ ¼lesbian, gay, bisexual, transgender, and queer.
Table 4. Core elements and teaching methods for a first-year
curriculum
Self-preparation: Video demonstration of sexual history role play
Self-preparation: Recommended reading on the sexual history
Self-preparation: Sexual history script
Didactic: Principles of sexual history taking (see “First-Year Content”)
Didactic: Sexual history role-play demonstration with simulated patient
Role play: Sexual history taking with peers with feedback
Role play: Sexual history taking in simulated patient scenario
Role play: Sexual history taking in context of larger patient encounter
(eg, complete history) in simulated patient scenario
Discussion group: Sexual health communication strategies and comfort
(self-reflection)
Formative evaluation: Video self-review of 1 of the above role plays
Formative evaluation: Objective structured clinical exam or group
objective structured clinical exam
J Sex Med 2018;15:1414e1425
Medical Education in Sexual History Taking 1419
Clinical Reasoning/Purpose-Driven Questions
Second-year students should be encouraged to ask questions
more specifically related to a chief symptom. They may, for
example, ask questions about pain during vaginal penetration for
a suspected diagnosis of endometriosis or questions about history
of chronic infections and allergic reactions for a suspected diag-
nosis of inflammatory vestibulodynia. The subtleties of identi-
fying the truly critical elements for evaluation in a particular
patient encounter compared with what should be deferred should
also be addressed, along with directing the conversation and
working within time constraints. Students at the second-year
level should be able to utilize their clinical knowledge to this end.
Questions for Specific Populations/Diversity of
Practices
Second-year students will benefit from in-depth discussion
about diversity in sexual practices and higher-level case exam-
ples.
11
This includes exposing students to questions relevant to
the needs of specific populations.
61
Though the spectrum of
sexual orientation has become more widely embraced throughout
the United States, a recent study suggests medical students,
residents, and fellows remain uncomfortable obtaining sexual
history from lesbian, gay, bisexual, transgender, and queer
(LGBTQ) individuals.
81
Medical students also lack knowledge of
the range of sexual practices engaged in by many same-sex
partners.
82
Students should have learned to include LGBTQ
patients in their questions during their first year (outlined in
Table 2); however, many will need additional education for more
in-depth counseling. Additionally, students should learn perti-
nent questions for sex workers; victims of sexual trauma; sexual
enhancement device use; and those who engage in diverse sexual
activities including group sexual activity, bondage, dominance,
sadism, masochism, and paraphilias.
59
Although diagnosis,
treatment, and management are outside the scope of this article,
students may need background knowledge lectures in order to
better direct patient interviews.
6,7
Sexual Problem-Based History
Second-year students should advance beyond screening for
sexual problems (Table 2) and should learn the basics of con-
ducting a sexual problem-based history. This begins by learning
to contextualize patient problems and establish intent to help.
Students should then learn to appropriately inquire about the
problem’s impact on relationships, partner response to the
patient’s problem, and patient motivation for improving
problems.
6,7,46
Counseling
Second-year students should begin training in sexual health
counseling. This includes explaining a diagnosis, soliciting and
addressing questions, and utilizing motivational interviewing
techniques to address barriers to change. Some programs may
already have established coursework in motivational interviewing
and can explain how these skills can be generalized to sexual
health discussions. For example, students may benefit learning to
elicit a medication side effect from a contraceptive method and
how to counsel toward a different method. As students complete
coursework in contraception, sexual problems, and STIs, they
will be better equipped to respond to patient concerns, questions,
and misconceptions.
Illness-Related Sexual Health Interview
Second-year students should be exposed to the impact of
illness on sexual function and the illness-related sexual health
interview. Programs can teach the BETTER model for assisting
students in bringing up sex and sexuality while caring for patients
with chronic illnesses, such as cancer.
83
The BETTER mne-
monic, developed specifically for cancer patients, stands for:
Bringing up the topic of sexuality; Explaining to the patient or
partner that sexuality is a part of quality of life; Telling the
patient about resources available to them (as well as gauging the
trainee’s ability and willingness to assist in addressing questions
and concerns); Timing the discussion to when the patient would
prefer, not only when it is convenient for the interviewer; and
Recording that the conversation took place and any follow-up
plans to further address patient concerns or questions.
83
A full
illness-related sexual interview is beyond the scope of a pre-
clinical education, but students may benefit from learning the
goals of an illness-related sexual health interview. Table 6 out-
lines a medical student-level illness-related sexual health
interview.
84
SECOND-YEAR TEACHING METHODS
Teaching modalities for second-year students are similar to
those of first-year students: self-preparation, didactics, role play,
standardized patients/SPs, and discussion groups. Didactic ses-
sions and SP encounters should be specifically tailored to
acquisition of more advanced content.
Didactics
Second-year clinical interviewing or physical examination
course didactics should emphasize the sexual history as a neces-
sary component of conducting a focused history. Students should
receive didactics specifically on taking a complex sexual history
and discussion of sexual problems, keeping in mind the content
areas described above, including a demonstration of a counseling
Table 6. Goals of illness-related sexual health interview for
medical students
84
Screening and identification of sexual concerns or diagnosis of
dysfunction
Clinical assessment of sexual dysfunction, origin, and impact on pa-
tient’s life
Empathy and counseling utilizing normalization and support
Referrals for counseling, physical therapy, and/or a medical specialist as
needed
J Sex Med 2018;15:1414e1425
1420 Rubin et al
visit. Programs may wish to incorporate this into didactics on
caring for specific populations. When possible, focused sexual
history items should be included in existing didactic descriptions
of clinical presentations. Instructors should include scenarios in
which patients have sexual health problems to normalize and
emphasize the importance of these clinical discussions. If dedi-
cated class time is not possible, programs should seek out videos
of advanced sexual history taking for students to view. AAMC
has developed a series of online videos that can be used for this
purpose.
45,85
Role Play
For teaching the advanced skills outlined above, programs may
need to reach outside their normal sphere of hired SPs. Some
programs may find senior medical students or members of
community organizations such as LGBTQ community groups or
cancer survivorship groups willing to volunteer for these role
plays.
7
Role play is particularly important in teaching inter-
viewing skills pertinent to discussing sex and sexuality with
LGBTQ individuals.
81
The AAMC has developed a series of
online videos specifically for sexual history taking with LGBTQ
patients.
45,85
Should programs wish to incorporate sexual history
taking for transgender patients into their role plays, it is
important to have transgender actors/volunteers playing such
patients as to avoid inadvertently offensive portrayals.
SP/Standardized Patients
Comfort with increasingly complex SP encounters is an
important skill second-year students must master in advance of
their clinical rotations and for passing the Step 2 Clinical Skills
U.S. Medical Licensing Exam.
86
While peer-to-peer role play
with large group feedback may not be time-efficient or high
stakes enough for second-year students, students should be given
time to practice their skills with a SP or faculty member with
feedback.
11
Sexual history should regularly be included in SP
encounters designed to represent general or all-encompassing
clinical scenarios. Excluding this portion of the history re-
inforces it as unimportant. SP encounters may be important for
second-year students in the form of evaluation, described below.
SECOND-YEAR EVALUATION METHODS
Second-year evaluations should be summative as students
should have advanced beyond needing targeted sexual history-
specific evaluations. Instead, sexual history taking should be
incorporated into pre-existing OSCE or group OSCE that
evaluate overall communication or interviewing skills. Students
should be required to ask relevant sexual history questions in
order to pass mid-year clinical exams that evaluate complete
history taking, focused history taking, or time management.
Finally, sexual history should be included in the history taking
components of a summative year-end OSCE.
DISCUSSION
The first-year curriculum we’ve described is focused on
acquiring satisfactory basic sexual history taking skills, including
both sexual risk (ie, the 5 Ps)
58,59
as well as the sixth P (plus),
which encompasses the assessment of trauma, violence, support
for gender identity and sexual orientation, sexual satisfaction, and
sexual health concerns/problems. The second-year curriculum is
focused on incorporating improved clinical reasoning, empha-
sizing sexual history taking of diverse populations and practices,
and including the impact of illness on sexual health. For more
effective learning, teaching methods must include varied formats
including student self-reflection, didactics, video demonstrations,
SP encounters with immediate feedback, and role play. Evalua-
tion may be best as a formative OSCE in the first year and
summative OSCE in the second year.
Several barriers exist regarding the incorporation of a compre-
hensive education in sexual health communication into an existing
undergraduate medical school curriculum.
45
First, pre-clinical
curricula are becoming increasingly condensed; and the majority
of lecture time is often devoted to only those topics tested on the
U.S. Medical Licensing Exam. In an effort to address monetary
and temporal constraints, lectures, role plays, and discussion
groups must be organized and efficient. Whenever possible, sexual
history taking should be included into existing courses on clinical
interviewing or human reproduction. Students should be advised
that their skills must be practiced outside of class time.
Additionally, faculty endorsement can be difficult to obtain, as
faculty themselves may be uncomfortable discussing sexual health,
may lack experience in sexual medicine, or may not take sexual
histories in their own practices. This in turn can shape the "hidden
curriculum," ie, the practices learned by observing faculty mem-
bers’attitudes or behavior. Utilizing faculty sexual health cham-
pions to rally for curriculum committee support can mitigate issues
surrounding faculty buy-in. Clinical faculty will need professional
development around discussing sexual health.
52
Content for faculty
is similar to that for students and should include a script, current
standard operating procedures or best practices in sexual history
taking, and webinars or video modules. Materials are frequently
available fully formed and free of cost. For example, the National
LGBT Health Education Center, a program of the Fenway Insti-
tute, has developed a free, modifiable, all-staff sexual history
training presentation that is available online.
59
Similarly, MedEd-
PORTAL
87
has a number of well-developed sexual history taking
curriculum materials that can be used for faculty development.
Due to the nature of expert consensus, our proposed curric-
ulum is limited in that it is not yet validated. Ideally, validation
would comprise student appraisal of the individual curricular
components, including an assessment of which elements students
perceive to be most useful. Optimal validation needs to
also incorporate faculty input regarding the quality of the
implementation of curricular components and ideally patient
feedback regarding evidence of acquisition of skills. Assessment is
J Sex Med 2018;15:1414e1425
Medical Education in Sexual History Taking 1421
needed regarding the effectiveness of this curriculum in teaching
sexual history taking across the spectrum of sexuality and illness
(eg, sexual orientation, gender identity, disability). To ensure the
appropriate skills are being acquired, validation may also occur
using assessments before and after curricular intervention via
OSCEs and/or observed patient encounters.
Our proposed curriculum represents expert consensus on the
ideal curriculum that will be attainable for some programs. This
curriculum is aspirational, and many programs will only be able to
incorporate those aspects that align with their current curriculum.
Programs may find they need to incorporate some of this material
into the clinical years. Indeed, next steps in this field would be
creating sexual health communication skills curricula in relevant
clerkships including obstetrics and gynecology, internal medicine,
family medicine, pediatrics, ambulatory care, psychiatry, and
urology. At present, it is of the utmost importance that medical
schools use the dedicated pre-clinical time to create the foundation
for excellent clinical sexual health communications skills.
CONCLUSION
This article is a summary of the consensus from 2012, 2014,
and 2016 Summits on Medical Education in Sexual Health on
best practices in medical education in sexual history taking and
serves as a blueprint for sexual health communication curricula in
pre-clinical undergraduate medical education in North America.
The ideal model for developing these skills includes a spiral
curriculum utilizing multiple educational modalities that weaves
the core concepts of sexual history taking into the advanced skills
required for medical students in the clinical setting.
ACKNOWLEDGMENTS
The authors of this article would like to acknowledge the
Program in Human Sexuality in the Department of Family
Medicine and Community Health at University of Minnesota
Medical School as well as additional members of the Subcom-
mittee on Sexual History Taking Education: Alyson Kristensen
and Daniel E. Rohe, PhD.
Corresponding Author: Elizabeth S. Rubin, MD, Department
of Obstetrics and Gynecology, Hospital of the University of
Pennsylvania, 3400 Spruce Street, Fifth Floor Dulles Building,
Philadelphia, PA 19104, USA. Tel: 215-662-2459; Fax: 215-
349-5893; E-mail: elizabeth.rubin@uphs.upenn.edu
Conflict of Interest: The authors report no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Elizabeth S. Rubin; Jordan Rullo; Joycelyn Elders; Sharon J.
Parish
(b) Acquisition of Data
Elizabeth S. Rubin; Jordan Rullo; Sharon J. Parish
(c) Analysis and Interpretation of Data
Elizabeth S. Rubin; Jordan Rullo; Sharon J. Parish
Category 2
(a) Drafting the Article
Elizabeth S. Rubin; Jordan Rullo; Sharon J. Parish
(b) Revising It for Intellectual Content
Elizabeth S. Rubin; Jordan Rullo; Perry Tsai; Shannon Criniti;
Joycelyn Elders; Jacqueline M. Thielen; Sharon J. Parish
Category 3
(a) Final Approval of the Completed Article
Elizabeth S. Rubin; Jordan Rullo; Perry Tsai; Shannon Criniti;
Joycelyn Elders; Jacqueline M. Thielen; Sharon J. Parish
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SUPPLEMENTARY DATA
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.jsxm.2018.08.008.
J Sex Med 2018;15:1414e1425
Medical Education in Sexual History Taking 1425
