In two resident clinics in a large urban area, the strongest demographic factor associated with a documented sexual history was patient age, with increasing age being inversely related to a documented sexual history. The lack of documentation of marital status was also associated with absent documented sexual history. Resident gender, gender concordance, or resident post-graduate year was not associated with documentation. Patient STI concern, contraceptive use, genitourinary or abdominal complaints, and the performance of any HCM were all associated with documentation of sexual history. Notably, Papanicolaou testing and prostate exams were not positively associated with documentation of a sexual history.
Consistent with our results that increasing patient age was associated with a decrease in documentation of a sexual history, medical students, and physicians often cite patient age as a barrier to sexual history-taking.15,16,22
However, avoiding risk assessment for STIs in older people because of discomfort with the topic area has potential deleterious effects on patient care. Further, older adults are likely to have chronic diseases such as diabetes and hypertension, which often lead to sexual dysfunction. A large nationally representative probability sample of community-dwelling men and women 57 to 85 years showed that while self-reported sexual activity declines with age, the majority of the respondents were sexually active in the past 12 months. Approximately half of the sexually active respondents had a sexual problem, yet only 38% of men and 22% of women reported discussing sex with a physician after the age of 50.23
Patients in gynecologic studies were more likely to discuss their sexual concerns if prompted by their physicians.24
In addition to concerns about sexual dysfunction, patients over 50 continue to be at risk of new HIV infection and other STIs. According to the CDC, the incidence of new HIV infection diagnosis stayed the same or increased in people age 50 and older from 2005–2008. In the 50–59 age group, HIV incidence increased from 13.1 to 14.5 per 100,000 people.25
Though a brief update on their sexual history may be sufficient in elderly patients well-known to the provider, all adult patients require a regular sexual history for appropriate screening and treatment of sexual concerns and STIs.
Although the performance of any aspect of HCM was associated with documentation of a sexual history, performance on a Papanicolaou test or a prostate exam was not associated with documentation of a sexual history. Although it is recommended that all adult women age 25 or younger receive annual chlamydia testing, only high-risk women over 25 years require STI screening with Papanicolaou testing.5
Physicians need a current sexual history to assess whether women are high-risk. Although, to our knowledge, this study is the first to objectively study documentation of sexual history during preventive visits, other studies have shown that primary care providers are less likely to take a sexual history in asymptomatic patients.7,10,16
Our findings are also consistent with a large CDC survey of primary care physicians in five specialties that showed self-reported rates of STI screening far below national guidelines.2,26
Educational efforts should focus on the importance of sexual history-taking for asymptomatic individuals.
Notably, documentation of a sexual history was often missing even when indicated by the clinical problem, when documentation rates could be expected to be 100%. Of visits that specifically noted STI concerns, 19% had no documentation of a sexual history. Only 55% of charts with an abdominal or genitourinary complaint had any component of a sexual history documented. These findings are consistent with a large multispecialty survey where 21% of physicians reported that they would not take a sexual history even if they felt it was “relevant to the chief complaint.”10
Though abdominal and genitourinary complaints do not necessarily have a sexual etiology, at least a brief sexual history is required to complete a differential diagnosis.
Resident-patient gender concordance was not associated with documentation of a sexual history. In one of the few studies to examine the impact of patient-physician gender concordance, primary care physicians reported high levels of discomfort in discussing a sexual history with patients of the opposite gender.17
In an older study of family physicians that recently completed training in Quebec, physicians reported no gender difference in frequency of taking sexual history or comfort in taking a sexual history.18
While gender discordance may lead to greater provider discomfort, our results suggest that gender discordance was not associated with sexual history-taking practices.
Given that sexual history-taking is a sensitive area of history-taking, residents may benefit from both communication skills training around challenging topics and curricula focused on sexual history-taking. A survey of physician attendees of a workshop on erectile dysfunction found that training in communication skills was the strongest predictor of sexual history-taking practices.27
A recent survey of medical students showed that students with less sexual experience also reported less comfort addressing sexual concerns.28
Training in sexual history-taking specifically and communication skills in general may help to overcome physician lack of comfort due to inexperience or other factors.
This study was limited by generalizability and resident sample size. Although the clinics serve a diverse population, the study involved charts from residents at one academic institution. Larger studies in diverse clinical settings could confirm the findings of this study. Our finding that primary care residents were more likely to document a sexual history than hospitalist residents needs to be considered cautiously, because of the small numbers of residents in each training track represented in the sample. Since this is the first study to our knowledge using chart review or other objective means to assess sexual history-taking practices, we cannot compare our results with other studies using the same methodology. However, the knowledge of the resident, patient, and visit factors associated with documentation of a sexual history gained from the resident charts studied does provide a starting point for the development of targeted educational or quality improvement interventions.
The use of chart review as the method of assessing factors associated with sexual history-documentation is a second potential limitation of this study, because physicians may have neglected to document aspects of a patient’s history that were discussed in the visit or may have documented issues that were not discussed. Studies investigating the correlation between either direct observation or patient report and chart review have reported a highly variable range—40% to 93% percent—depending on the activity being reviewed. Activities such as documenting a dichotomous answer to the presence of pain have a high correlation, whereas activities such as reporting the effectiveness of the treatment have the lowest correlation.29,30
This study may have underestimated the actual sexual history-taking practice of physicians, leading to ascertainment bias. Ascertainment bias could have affected the association among patient, resident, and visit factors in favor of the null hypothesis for individuals without symptoms. Alternatively, it could have strengthened the association between symptoms or STI concerns and sexual history. Despite this limitation, chart review was the appropriate design for this study because it eliminated the risk of the Hawthorne effect in direct observation or overestimation from self-report.31–34
The validity of our results are also supported by the consistency of our findings with patient reported frequencies11,23
and the findings of an objective assessment of internal medicine resident STI screening skills.12