LET’S TALK! Comprehensive Sexual Health History 

Written by Kate Mitchell, DNP, CNM, WHNP-BC, IBCLC  

Engaging patients in open, non-judgmental conversations about sexual health is an essential component of reproductive health care. These conversations allow Certified Nurse-Midwives and Certified Midwives (CNMs/CMs) to provide individualized recommendations about sexually transmitted infection (STI) screening, contraception, and STI prevention, including vaccination. Ultimately, the goal of taking a sexual health history is to share individualized, evidence-based recommendations so that people can make informed decisions about their own sexual health.  

Background 

According to the Centers for Disease Control (CDC), the United States reported over 2.4 million cases of chlamydia, gonorrhea, and syphilis in 20231 . Chlamydia remains the most prevalent STI in the United States, with 1,648,568 cases, followed by gonorrhea with 601,319 cases, and syphilis with 209,253 cases1 . Of particular concern for reproductive health specialists like CNMs/CMs is the marked increase in syphilis infections during pregnancy over the past decade: according to national data, congenital syphilis cases totaled 3,882 in 2023 compared to 362 cases in 2013.1-2 While syphilis is a curable STI, infection during pregnancy can result in congenital syphilis, which can cause lifelong health consequences for the neonate or stillbirth.3  

Health inequities 

The burden of STIs remains disproportionately high among adolescents and young adults under 24 years, who accounted for 56% of all chlamydia cases in 2023.1 Additionally, certain regions in the United States, specifically the American South and West, and certain racial groups, specifically Black Americans and Native Americans, continue to experience higher rates of infection due to systemic health inequities, including racism and the lack of targeted health care interventions.4-5 One study  specifically links the rapid resurgence of congenital syphilis in the United States with decreased federal funding for STI prevention programs over the past 20 years.5 Undeniably, STIs are a complex public health issue that requires broad national surveillance and targeted local attention.  

Preparing yourself for the visit 

In providing sexual health care, you will encounter diverse sexual identities, orientations, and lived experiences; you need to be prepared to provide care without judgment and be well informed about emerging sexual health trends for diverse populations. During highly personal history taking and intimate examination, it is vital that CNMs/CMs explain the indications for questions or exams and seek active patient consent. If patients decline the conversation or decline physical exam, respectfully offer reasonable alternatives, such as completing a written questionnaire, performing self-collection of screening tests, and/or reviewing public health recommendations in their own time.  

Use gender inclusive language that avoids assignment of relationship (use “partners” vs. “husband/wife” or “boyfriend/girlfriend”), avoid stigmatizing terms (avoid “promiscuous”, “one night stand”, etc.), and disclose results using unambiguous language (say “your test result shows a current chlamydia infection, which is curable with antibiotics” vs. “you’re positive”). Practice difficult or awkward conversations with your colleagues so you can find your preferred flow and natural language.   

Acknowledging that STIs are common, always treatable, and often curable helps reduce the stigma of screening and treatment. While your education and professional experience may inoculate you from the social stigma associated with STIs, some of your patients may feel distress when they receive unexpected sexual health news. Be prepared to respond calmly and emphatically to such reactions. Ensure you are prepared to offer support services or referral to support services.   

Basic risk reduction strategies 

Effective risk reduction involves  targeted interventions: 

• Condom Use: Consistent and correct use of internal/external condoms significantly reduces the transmission of many STIs and reduces unintended pregnancy. https://lacondom.com/our-partners/ 

• Contraception: For patients who do not desire conception, provide detailed contraception counseling based on their medical eligibility and contraception priorities. Consider a standing prescription for emergency contraception for eligible patients. https://www.bedsider.org/ 

• Regular Testing: Routine STI screening is recommended for sexually active individuals. More frequent screening schedules may be considered for folks at higher risk of infection or based on patient preference. https://gettested.cdc.gov/ 

• Vaccination: Vaccines are available for certain STIs, such as human papillomavirus (HPV), Hepatitis B, and MPox. Vaccination reduces risk of infection, lessens infection severity, and reduces personal risk of associated cancers.6-7 https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html https://www.cdc.gov/vaccines/vpd/hepb/hcp/index.html https://www.cdc.gov/mpox/hcp/vaccine-considerations/vaccination-overview.html?CDC_AAref_Val=https://www.cdc.gov/poxvirus/mpox/interim-considerations/overview.html 

• Pre-Exposure Prophylaxis (PrEP): For individuals at higher risk of HIV, PrEP is a preventive medication that, when taken consistently, can reduce the risk of HIV acquisition by up to 99%.8 https://www.cdc.gov/hivnexus/hcp/prep/index.html 

• DoxyPep: DoxyPEP is a post-exposure medication regimen that reduces the risk of syphilis, chlamydia, and gonorrhea for gay/bisexual/MSM and transgender women.9 https://www.cdc.gov/sti/hcp/doxy-pep/index.html 

• Partner expedited therapy (EPT): EPT is the delivery of medications/prescriptions by an individual determined to have a current sexually transmitted infection to their sexual partner(s) without requiring clinical assessment of said partner(s). https://www.cdc.gov/sti/php/ept-legal-status/index.html 

Conclusion 

Inquiring about a patient’s sexual health history is not done merely to categorize risk but to offer targeted recommendations. By utilizing respectful and inclusive language, providing accurate information, and offering compassionate intervention, CNMs/CMs play a pivotal role in promoting sexual health and improving public health. 

References 

1. Centers for Disease Control and Prevention. Sexually Transmitted Infections Surveillance 2023. Atlanta: US Department of Health and Human Services. 2024. 
2. Gregory E, Ely D. Trends and Characteristics in Maternal Syphilis Rates During Pregnancy: United States, 2016-2022. NCHS Data Brief. 2024;(496):1-8. PMID: 38358322. 
3. Galvis AE, Arrieta A. Congenital Syphilis: A U.S. Perspective. Children. 2020; 7(11):203. https://doi.org/10.3390/children7110203 
4. Smullin C., Wagman J., Mehta S., Klausner J. A Narrative Review of the Epidemiology of Congenital Syphilis in the United States From 1980 to 2019. Sex Transm Dis. 2021;48(2):71-78.  
5. Sankaran D, Partridge E, Lakshminrusimha S. Congenital Syphilis-An Illustrative Review. Children (Basel). 2023;10(8):1310. doi: 10.3390/children10081310.  
6. Farrar, J, Lewis NM, Houck K, et al. Demographic and Clinical Characteristics of Mpox in Persons Who Had Previously Received 1 Dose of JYNNEOS Vaccine and in Unvaccinated Persons – 29 U.S. Jurisdictions, May 22-September 3, 2022. MMWR Morb Mortal Wkly Rep. 2022; 71(5152): 1610–1615. https://doi.org/10.15585/mmwr.mm715152a2 
7. McClung N, Gargano J, Bennett N, et al. Trends in Human Papillomavirus Vaccine Types 16 and 18 in Cervical Precancers, 2008-2014. Cancer Epidemiol Biomarkers Prev. 2019;28(3):602-9 
8. Chou R., Spencer H, Bougatsos C, Blazina I, Ahmed A, Selph S. Preexposure Prophylaxis for the Prevention of HIV: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2023;330(8):746–763. doi:10.1001/jama.2023.9865 
9. Flores J., Davis A., Hazra A. Doxycycline Postexposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infection. JAMA. 2025; 333(3):248–249. doi:10.1001/jama.2024.24540