Practice of Medicine - I

Interviewing on Sensitive Topics: Sexual History, Sexual Practices, and Domestic Violence Christine M. Peterson, M.D.

9 October 2006

Taking Sexual and Domestic Violence Histories

Objectives

After attending these lectures, completing the assigned readings, and participating in the related small group sessions, the student will be able to:

1. Demonstrate the ability to ask appropriate questions and convey non-judgmental responses during sexual and violence history taking.

2. Explain why sexual and violence histories are part of a patient’s medical history

3. Discuss reasons why clinicians sometimes feel uncomfortable about taking sexual and violence histories from their patients.

4. Describe environmental factors conducive to clinician and patient comfort during sexual and violence history taking.

5. Demonstrate verbal transitions between less sensitive and more sensitive portions of the medical interview.

6. Be aware of and direct a patient to appropriate professional and community resources for services related to sexual and domestic violence concerns.

Taking a Sexual and Violence History

I. Physical environment

A. Privacy

B. Non-assumptive decor, pamphlet racks, personnel

II. Interpersonal climate

A. Assurance of confidentiality (within legal bounds)

- explicit (in words)

- implicit (by behavior)

B. Communication of reasons for detailed and/or probing questions.

III. Format

A. Oral dialogue vs. written questionnaire

IV. Content

A. Non - assumptive

B. Non - judgmental

C. Empathic without emotionality

D. For a basic history when establishing a primary care relationship, include:

Relationships

1. Are you involved in a significant relationship?

2. Tell me about your living situation. Who shares the household with you?

3. Tell me about the people who are important to you. Where do you get the

most support?

4. Are your relationships satisfying or are there any concerns you’d like to discuss?

Behaviors

1. Are you currently sexually active? (As defined by patient - virtually always means
one form or another of intimate touching.) With men, with women, or with both?

2. Have your past sexual partners been men, women, or both?

3. Do you have any need to discuss birth control?

4. How are you dealing with the issue of “safer sex”?

5. Have you had a new partner or a change in your sexual activity since your last

visit?

6. Is there anything else I should know about your sexual history in order to give

you the best care?

E. When circumstance call for a complete or problem-focused sexual history, inquiry must include at least the following:

  1. Are you currently involved in a sexual (see D. 1 above) relationship? Query re specific sexual practices (e.g., intercourse, manual touching, oral-genital contact, anal penetration, use of sex toys, use of mind-altering substances, etc.) when indicated by symptoms or findings.
  2. Have you been sexually active in the past?
  3. Have you or has any partner ever had other sexual partners? Are you
    currently sexually involved with one person or more than one person?

4. Do you have sexual relations with males or females or both?

5. Is your sexual activity satisfactory for you? Do you have pain or any other
difficulties with sex?

6. Do you have any need for contraceptive information or for a contraceptive method?

7. How do you protect yourself from sexually transmitted diseases?

8. Have you ever been hurt or frightened while engaged in sexual activity? Have you ever caused someone to be hurt or frightened during sexual activity?

9. Is there anything we haven't discussed that you think is important for me to know?

[The above questions are adapted from the Sexual Health History Guide

by L. Fertitta, M.S., R.N.C.]

F. Every primary care patient should be questioned about past or current abuse:

1. Are you now or have you been in a close relationship where you were hurt in any way? [What happened?]

G. For any injury, particularly in children, pregnant women, or when the injury is in an area
that is usually covered with clothing:

1. Did someone do this to you?

And, if there is evidence of, or a history of injury:

2. Do you have a plan for your own safety if something like that seems like it might happen again?

H. Additional information – appropriate in establishing a primary care relationship or

whenever a presenting problem might be related to sexual activity:

1. consequences of sexual activity

a. pregnancies, outcomes

b. STD's, treatment; partner treatment

c. physical or emotional injuries following unwanted sex

2. circumstances of sexual activity

a. coercion

b. alcohol or other drug use

c. for drugs or money

3. interest in addressing sexual dysfunction and/or relationship problem

V. Summary for patient with respect to patient's current health status and health risks

Part 2: Small group sessions with scripted role plays about sexual and domestic violence issues. (Oct. 10 or 12, 2006))

Part 3: The final videotaped standardized patient interview at the end of the semester will

require you to ask the patient about sex/violence/substance abuse issues.

(~November - as assigned).

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HELPFUL HINTS:

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RESOURCES

For medical students with sexual or abuse concerns:

Student Health Gynecology (924-2773)

Student Health General Medicine (982-3915)

Student Health Counseling and Psychological Services (924-5556)

For students and other patients as well:

Sexual Assault Resource Agency (977-7273)

UVa Women’s Center (982-2251)

Shelter for Help in Emergency (293-8509)

Region Ten Community Services (972-1800)

UVa Emergency Room (924-2231)

MedEd(PoM I):\sexhistho06