Circling Back to a Better Sexual History

Jonathan Kole

doi:10.1370/afm.2299

THE INNOVATION

Pressed for time in the typical adolescent patient health encounter, the usual sexual history can often feel rushed and incomplete. With but a pen and the exam table paper scroll, I propose a simple technique for a more thorough and efficient sexual history, improving both clinician and patient experience.

WHO & WHERE

This technique will be useful in all clinical encounters with adolescent patients, helping ensure clinicians can acquire essential information from sexual history for appropriate care.

HOW

During the clinical encounter, as I move into the social history, following my questions of gender identity and sexual attraction, I draw 5 circles on the exam table paper and clearly write a single word of “Butt,” “Vagina,” “Penis,” “Mouth,” and “Hand” within each. I ask the adolescent patient, “Can you read my handwriting?” to which they nod yes. Then with a simple pen stroke, drawing an arrow from 1 circle to another, I ask “Is this happening?” (Figure 1). With just a line connecting “Penis” to “Vagina” and this 3-word question, every adolescent patient I’ve screened seems to know exactly what I am asking. As they answer, I draw more lines, connect more circles, and my follow-up questions follow accordingly. “How many partners have you had that type of sex with? Do you feel safe with that activity? Do you use protection when you do this? Have you ever had an infection or pregnancy after this?” Pointing to the arrows and using this visual support, I more easily assess for all forms of wanted and unwanted sexual contact and have found patients more clearly able to share their practices and risk factors, often without saying a single word. This technique efficiently allows me to best understand my patients and counsel accordingly. After a comprehensive assessment, my last line always connects “Vagina” to “Butt.” Why? When asked about this practice, all patients of any sex, gender, or sexual orientation appear confused and say “No.” And at this juncture, I smile and joke, “Of course not, how would that even work?” From juvenile detention clinics to wealthy suburban private practices, I have never met a patient who doesn’t smile back in amusement. In one moment, I take a possibly embarrassing or awkward encounter for an adolescent patient (or the clinician) and can make it a point of bonding, a reminder that sex can be discussed and not feared. Finally, I rip the exam table scroll and throw their lines and circles into the trash, reminding them of, and visually confirming, their patient confidentiality.

Figure 1

Lines and Circles

LEARNING

Having taught this technique to countless students, residents, and faculty, in 1-on-1 sessions or larger lectures, it is consistently positively received. Clinicians who try it in the clinical encounters overwhelmingly found this technique for sexual history more comfortable, enjoyable, efficient, and thorough than their standard practice. It reminds us of the power of visual aids and opportunities to infuse creativity in all areas of clinical practice, including obtaining other types of sensitive clinical information.