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Taking a Sexual History

A four-panel collage of Transforming Health photos featuring transgender people. Three panels show individuals speaking with health professionals. One panel shows an individual filling out a form.

Providing appropriate sexual risk-reduction counseling hinges on an accurate sexual history. However, health care providers sometimes feel uncomfortable talking about sex and sexuality. Although this may be the case, research suggests that brief discussions between health care providers and patients during routine clinical care are very effective at helping patients modify their sexual behaviors. In addition, sexual health is an integral part of overall health, and many patients want to discuss sexual health with their providers.1 This is also true of many transgender people; however, disclosing sexual history may be particularly sensitive for transgender people because of prior experiences of discrimination in health care.

Here are some helpful questions for discussing sexual orientation and activities:

  • “What types of sex do you have?” For example, ask, “Have you had any anal intercourse?” If yes, “Was it receptive? Insertive? Was a condom always used?”
  • “Can I ask you a few questions about your sexual partner(s)?”
  • “What do you think about using condoms?” instead of “Do you use condoms?”
  • “Some of my patients find it difficult to talk to a potential sexual partner about HIV. What do you find to be the best way to disclose your HIV status?”

Taking a Sexual History from Transgender People

Experts form The Fenway Institute suggest that providers may find it helpful to keep the following points in mind when taking a sexual history from transgender people:

  • Providers can ask patients for their gender pronoun simply by inquiring, “What name and pronoun would you like us to use?” or “I would like to be respectful—how would you like to be addressed?” In addition providers can what terms they use for their bodies or specific body parts.
  • As with all patients, consider assuring transgender people that the questions being asked are important for their medical care and well-being. Providers can also remind them that the answers will be kept confidential.
  • It is important to avoid assumptions about patients’ sexual orientation or the gender or gender identity of their partners. Transgender people may be of any sexual orientation, and their partners may be cisgender men or women or other transgender people.
  • In addition, as with all patients, it is crucial to avoid assumptions regarding the types of sexual activity (e.g., oral, anal, vaginal, or no sexual activity at all) that transgender people engage in. Providers can begin to elicit this information with open-ended questions. Whether or not the patient is taking hormonal therapy and/or has undergone surgeries may affect the answers to these questions.
  • Some transgender people, specifically transgender women, engage in sex work,2 often because employment discrimination limits other avenues for making a living, or they receive nonmonetary items such as food, drugs, or shelter. This is often called “survival” sex.3 Consider asking sexually active patients if they have ever exchanged sex for money or other goods, and make sure to avoid any body or language cues that may be perceived as judgmental.
  • Although HIV and other sexually transmitted diseases disproportionately affect transgender women compared to other populations, some transgender women may not be sexually active or may be in long-term, mutually monogamous relationships and thus have a low risk of HIV and other sexually transmitted diseases. Health care providers should not assume that a patient is at high risk on the basis of gender identity; rather, assessment about risk should be based on each individual’s sexual history. In addition, integrating the assessment of social determinants of HIV (e.g., employment status, food security, housing, insurance status, social exclusion, stigma) with sexual history shows that health care providers see the whole patient as someone whose health is multifaceted, thereby building trust and a basis for comprehensive care planning.
  • Transgender people may be at any stage of the transition process when seeking care. Some may not be taking hormonal therapies or have had surgery. Others may be using hormones but not have had surgery, and still others may have undergone one or more surgeries. For transgender women, surgeries can include facial cosmetic procedures, breast augmentation, orchiectomy, and the creation of a neovagina. For transgender men, surgeries can include facial cosmetic procedures, mastectomy and chest reconstruction, hysterectomy, bilateral salpingo-oophorectomy and genital transformation. When medically necessary (e.g., taking a sexual history), health care providers may consider asking about current anatomy and what, if any, hormonal or surgical interventions have been undertaken.
  • The following are some examples of questions addressing sexual history:
    • “It’s important for me to understand your medical history in detail to provide you the best health care possible.”
    • “Do you now or have you ever used hormonal therapy, including hormonal therapy not prescribed by a health care provider?”
    • “Have you ever had any surgeries or other procedures? If so, tell me about the surgeries you have had.”
  • In addition to asking about risk behaviors, a complete sexual history can also focus on and address any concerns about sexual function and satisfaction. Hormonal therapies tend to improve the quality of sexual experience among transgender people.4 Open discussions about therapy options can reinforce the health care provider’s commitment to supporting all aspects of transgender people’s health and facilitate both the health care process and the patient–provider relationship.
  • In the process of taking a sexual history, health care providers might identify patients who face a high risk of getting or transmitting HIV and other sexually transmitted diseases. Visit HIV Risk Reduction Strategies for key strategies.
Evidence that ongoing, brief counseling increases safer sexual behaviors Decline in sex without a condom
(insertive and receptive anal/vaginal intercourse and insertive oral sex) from 7.1 mean estimated events at baseline to 1.5 mean estimated events at 18 months (P<0.05) after patients participated in ongoing brief discussions about safer sexual behaviors. In patients who were not counseled, a significant increase in unprotected sex was seen from 2.06 mean estimated events at baseline to 9.61 mean estimated events at 18 months (P<0.01)
Fisher JD ET AL. J Acquir Immune DeFIc Syndr. 2006; 41:44–52
Decline in sex without a condom
(anal or vaginal intercourse) from 42% at baseline to 26% at 6 months and to 23% at 12 months (P<0.001) after patients were given targeted counseling including prevention messages.
Gardner Li et al. AIDS Patient Care STDS. 2008; 22:657–635
Fewer sexual partners
(at follow-up, a mean of 8.1 sexual partners for the control group, versus a mean of 4.3 sexual partners for those who participated in brief discussions about safer sexual behaviors. P<.03)
Rose CD Et Al. J AcquiR Immune Defic SyNDR. 2010; 55:572–581
Decline in STD Acquisition
Including syphilis, chlamydia, and gonorrhea (8.8% to 4.2%, P<0.04) within 1 year after patients were screened for STDs and participated in ongoing brief discussions with their providers about safer sexual practices.
Patel P et al. Sex Transm Dis. 2012; 39:470–474

A Note on Terminology

Transgender is used here as an umbrella term to describe people who have a gender identity that is different from their sex listed on their birth certificate. Gender identity is on a spectrum. It is important to keep in mind that although some transgender people prefer the binary classification of men or women, many reject it. Instead, they may have other identities, such as non-binary, gender expansive, genderqueer, or trans-feminine/trans-masculine. These terms emphasize a broader view of gender and may provide a more nuanced understanding of what it means to be a transgender person.

A note regarding HIV research published in academic journals: An important consideration in research with transgender people is the challenge to accurately classify transgender women for surveillance/research purposes. Not all jurisdictions collect data on gender identity that include transgender people, and some researchers may use older methods that can misclassify transgender women as men who have sex with men. This can also happen as some transgender people may not identify themselves as transgender in health care settings due to fear of discrimination or previous negative experiences. This mix of limitations can result in over- or under-estimating the number of transgender people. As such, it is important to consider methodologies when interpreting data and surveillance findings. As the field is developing newer and more precise ways to identify transgender identity for research and surveillance purposes, it is important to consider methodological approaches, particularly for studies that include both men who have sex with men and transgender women. The most accurate method uses a two-step process, including two questions: “What is your current gender?” AND “What sex were you listed as at birth?” The large majority of studies cited in this document use a two-step process, however one is a meta-analysis and likely includes studies with a one-step process to determine gender identity. For more information about using a two-step process, please refer to the section Collecting Sexual Orientation and Gender Identity.

1 James SE, Herman JL, Rankin S, et al. The report of the 2015 U.S. Transgender Survey. http://www.transequality.org/sites/ default/files/docs/USTS-Full-Report-FINAL.PDF. Washington, DC: National Center for Transgender Equality; 2016.
2 Clark H, Babu AS, Wiewel EW, Opoku J, Crepaz N. Diagnosed HIV Infection in Transgender Adults and Adolescents: Results from the National HIV Surveillance System, 2009-2014. AIDS Behav (2017) 21:2774–2783.

Footnotes

  1. Nusbaum MRH, Hamilton CD. The proactive sexual health history. Am Fam Physician. 2002 Nov;66(9):1705-12.
  2. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey [Internet]. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force. 2011. [cited 2016 Aug 30]. 220 p. Available from: http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf
  3. Centers for Disease Control and Prevention. HIV risk among persons who exchange sex for money or nonmonetary items. 2016. Available from: http://www.cdc.gov/hiv/group/sexworkers.html
  4. Murad MH, Elamin, MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, Montori VM. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol. 2010 Feb;72(2):214-31.
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