Facilitators and Barriers in Sexual History Taking



Figure 5-1.
Screening and in-depth sexual health history .



If the patient’s sexual history seems directly related to the main complaint, a complete history is indicated for a thorough sexual assessment [27]. Relevant information ought to include2 sexual and reproductive history and current status (sexual partners and practice, past history and protection against STIs and prevention of pregnancy) in addition to past medical history and current health status (viz., endocrine system, neurologic diseases, cardiovascular disease, psychiatric illness and current use of prescription and over-the-counter medicines). A physical examination or laboratory testing could be used complementary to determine the physiologic factors involved in a sexual complaint [2].



Screening and In-Depth Sexual Health History


In obtaining a detailed sexual history alongside the assessment of each domain of function as to its individual or combined impact [2], the biopsychosocial model [28] provides a comprehensive holistic framework for it takes into account medical, psychological, intrapsychic, interpersonal, social, cultural and ethnic variables that may affect sexual health and function [7, 18] (Figure 5-2). Since sexual health encompasses many facets of a person’s life, the clinician needs to guard against simplistic thinking about the cause and treatment of sexual problems and take time to perform a comprehensive biopsychosocial assessment. This is essential to identify the predisposing, precipitating, maintaining and contextual factors3 responsible for the problem [10, 29].

A370636_1_En_5_Fig2_HTML.gif


Figure 5-2.
Biopsychosocial model of sexual health. [Adapted from Wylie KR. ABC of Sexual Health. John Wiley & Sons; 2015. With permission from Wiley].

Only by bearing this structure in mind while taking a sexual history, clinicians can offer more efficacious, efficient and better tolerated treatments by patients and their partners [18].



Barriers to Effective Sexual History Taking


Sexual health is important throughout the entire lifespan. Individuals of all ages and backgrounds are at risk and should have access to the knowledge and services necessary for optimal sexual health. Given the public health impact that these risks have, health professionals are instrumental in promoting sexual health. Nonetheless, issues around sexuality can be difficult to discuss because they are intimate and because there is great diversity in how they are perceived and approached [30].

Patients are becoming more demanding and clamour for explicit information and clear guidance in dealing with sexual problems and complaints . Most expect their health-care provider to be an expert in all aspects of sexual health [6]. Nonetheless, several obstacles impede the communication about sexual topics. The obstacles can be categorized as patient based and health-care provider based.

General barriers pointed out by patients are the lack of opportunity to discuss the subject, a sense of discomfort, embarrassment or shame when there is openness to approach it during consultation [23, 31]. Feelings of uncertainty whether sexual problems/concerns are part of health care and if the provider is the suitable specialist to treat sexual problems/concerns often undermine a transparent dialogue [23, 32]. Taboos held by society against the open discussion of sexuality can also constitute an impediment to seek professional help [33, 34].

The most commonplace health-care provider-based obstacle is the inadequate or insufficient training in sexual health [35] (Table 5-1). Despite much progress in the past years, medical schools often lack trained sexuality educators [36] and still have inadequate sex education curricula which fail to emphasize the importance of sexual functioning [5, 37]. This gap becomes even more pronounced attending to the fact that health providers are interested and recognize the importance in attaining expertise in sexual history taking but ended up showing marked deficit communication skills when in a consultation [35].


Table 5-1.
Health-care providers’ barriers to effective sexual history taking





















Inadequate/insufficient education or training in sexual health

Time constraints

Reimbursement concerns

Personal conservative sexual beliefs

Deficits in communication skills

Growing knowledge gap between developments in sexual medicine and the clinical skills of the clinician

Generational obstacles

Cultural differences of the practitioner and the patient

Limited time and concerns about insurance reimbursement can also hinder clinician’s capacity to take an open discussion about sexual issues, especially as sexual topics are often raised by patients towards the end of a consultation. Many providers are unaware that a simple query about sexual concerns and one or two follow-up questions only add 2 to 3 min to an appointment. If a more complete sexual history or assessment is warranted, a follow-up visit can be scheduled (and billed appropriately with ICD-9 codes), or a referral to a specialist in treating sexual dysfunctions can be made [2, 35].

When working with specific populations, conflicting attitudes and perceptions may emerge, and providers may have difficulties disconnecting from their own personal belief system . Also, they often rationalize not talking to clients about sexual issues by saying that clients do not raise the issue [36].

Moreover, the growing knowledge gap between developments in sexual medicine and the clinical skills of the clinician is also a reason elicited by providers for not taking a sexual history. This might be a consequence of lack of formal education and training which often leads to a lack of confidence in knowledge and mastery in this area [2, 32].

Finally, the age and gender of either the patient or the provider as well as cultural differences between both may also play a role in how information is exchanged [37]. Within a multicultural society , where cultural and religious differences are inevitable, these discrepancies are worrisome. The concern is that, because of these barriers, health professionals may shy away from taking sexual histories from patients and, thus, be unable to identify patients’ health needs [32].

So what are the remedies for this situation? How can the clinician become proficient in taking a sexual history? One way in which the clinician will gain comfort and ease in obtaining a sex history and performing a general examination is by practice [34]. If clinicians take the step of including sexual history more routinely into their daily practice, much ground can be gained. Increasing the frequency of sexual health inquiries will substantially improve sexual health care through earlier identification of sexual problems and intervention. Routine assessment of sexual health also provides opportunities for preventive care, such as immunization against hepatitis B and counselling on sexual risk taking [27, 37].

Barriers to sexual health care can also be removed by assuring medical education that teaches sexual health care as integral to health care in general [27]. For clinicians who remain uncomfortable with taking a detailed history, written sexual history inventories are also effective. Similarly, referral to clinicians with special interest in sexual function is always an appropriate alternative [37].


The Study


The main objective of this work was to explore, integrate and summarize current knowledge on the perceived obstacles and facilitators for taking a sexual history encountered by health professionals in their clinical practice. The exploration of providers’ perspectives is justified by the fact that health-care providers hold clinical and institutional knowledge nurtured with relevant information about the practices surrounding sexual history taking when examining patients.

The adopted posture was one of the eliciting emergent redundancies or disparities in terms of optimal care provision in specific settings and intervention areas, namely, sexual health education/promotion; STDs; sexuality and disease; sexual dysfunction; lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ); and sexual violence. This way, we aim to uncover key areas which require further research and tailored interventions in the context of sexual health promotion.

For this purpose, we employed a narrative review approach, preceded by a scoping analysis [38, 39], to determine the adequate and most cited terms in scientific search databases. This combined strategy seems well suited for first identifying the appropriate parameters of a review and its potential scope.


The Collected Information



Search Strategy and Selection Criteria


A narrative review of literature was conducted through a search of published studies contained in the PubMed and Web of Science electronic databases. Publication date (from January 1, 1995, to December 31, 2015) and language of the documents (English) were used as restriction filters. The search was undertaken on April 27, 2016, using both free-text and “medical subject headings” (MeSH) terms combined as alternatives: “sexual history”, “sexual evaluation”, “sexual assessment”, “sexual interview”, “barriers”, “facilitators”, “attitude of health personnel”, “sexual dysfunction”, “sexual disorder”, “patient-centred care” and “biopsychosocial model”. Details of the search terms are given in Table 5-2. Screening of the lists of references in the identified articles was used as additional strategy to identify otherwise unfound published articles.


Table 5-2.
The search strategy









Search terms and sequence

#1 “sexual history” AND “barriers”

#3 “sexual history” AND “attitude of health personnel”

#5 “sexual history” AND “sexual disorder”

#7 “sexual history” AND “biopsychosocial model”

#9 “sexual evaluation” AND “facilitators”

#11 “sexual evaluation” AND “sexual dysfunction”

#13 “sexual evaluation” AND “patient-centered care”

#15 “sexual assessment” AND “barriers”

#17 “sexual assessment” AND “attitude of health personnel”

#19 “sexual history” AND “sexual disorder”

#21 “sexual history” AND “biopsychosocial model”

#23 “sexual interview” AND “facilitators”

#25 “sexual interview “ AND “sexual dysfunction”

#27 “sexual interview “ AND “patient-centered care”

#2 “sexual history” AND “facilitators”

#4 “sexual history” AND “sexual dysfunction”

#6 “sexual history” AND “patient-centered care”

#8 “sexual evaluation” AND “barriers”

#10 “sexual evaluation” AND “attitude of health personnel”

#12 “sexual evaluation” AND “sexual disorder”

#14 “sexual evaluation” AND “biopsychosocial model”

#16 “sexual assessment” AND “facilitators”

#17 “sexual assessment” AND “sexual dysfunction”

#20 “sexual assessment” AND “patient-centered care”

#22 “sexual interview” AND “barriers”

#24 “sexual interview “ AND “attitude of health personnel”

#26 “sexual interview “ AND “sexual disorder”

#28 “sexual interview “ AND “biopsychosocial model”


Screening Process


All citations identified by the above searches were downloaded and duplicates removed. Titles and abstracts of the identified papers were independently screened by at least two authors for consensus on eligibility and content. In case of disagreement, the third author made a decision on whether to maintain or exclude the paper from the review. Potentially relevant papers were assessed according to the following inclusion criteria: (1) empirical and self-contained research documents, (2) articles in which the population under study was consisted of health professionals, (3) papers that explore the views of health professionals with regard to facilitators and barriers in taking a sexual history and (4) full texts which are in English. Studies published before 1995 and after 2015, without a focus on the sexual history taking and on professionals’ knowledge, attitudes or perceptions on that process, were excluded. Opinion articles and conceptual papers were also discarded from the review.

The screening covered an initial 10% of the articles to determinate the necessity to perform alterations in inclusion and exclusion criteria, being made redefinitions at this stage. Subsequently, all article titles and abstracts were appraised taking the reformulated inclusion/exclusion criteria into consideration.


Data Extraction and Quality Assessment


Data was extracted into a standardized matrix that included the area of the article (sexual health education/promotion, STDs, sexuality and disease, sexual dysfunction, LGBTQ, and sexual violence), authors, year of publication, sample characteristics, variables/measures, study design, major findings (including facilitators and barriers) and comments.

The authors independently appraised the quality of the evidence produced by studies, attending to the purposes of this review of enlightening the barriers and the facilitators for sexual history taking and identifying important areas for further research and tailored interventions.4

The papers were categorized by study design using the following categories: cross-sectional survey, literature review, qualitative study and intervention study.


Results


The study selection process is shown in Figure 5-3. A total of 56 (60%) articles from an initial list of 94 citations were considered eligible for this review. These articles were published between 1995 and 2015, the majority (n = 39; 70%) within the last 10 years. Not only the last decade was more prolific, but also new areas of research emerge, such as LGBTQ and sexuality and disease. In fact, six different research areas and one miscellaneous (with more than one area) were identified among the eligible studies, as it is shown in Figure 5-4.

A370636_1_En_5_Fig3_HTML.gif


Figure 5-3.
Fluxogram for article selection.


A370636_1_En_5_Fig4_HTML.gif


Figure 5-4.
Studies’ research areas.

Four major study methodologies were identified, as it can be seen in Figure 5-5 and Table 5-3. The majority of the analysed articles were cross-sectional surveys (n = 36; 64%), but also qualitative studies (n = 11; 20%), interventions studies (n = 6; 11%) and literature reviews (n = 3; 5%) were included.

A370636_1_En_5_Fig5_HTML.gif


Figure 5-5.
Studies’ methods.



Table 5-3.
1995–2015 Peer-reviewed studies and methodologies and areas



































































Methodology

Areas

Studies

Cross-sectional survey (n = 36; 64%)

Sexual health education/promotion (n = 14; 39%)

(Ariffin et al. 2015)

(Bouman and Arcelus 2001)

(Bull et al. 1999)

(Burd et al. 2006)

(Dadich and Hosseinzadeh 2013)

(Jolley 2002)

(Morand et al. 2009)

(Sobecki et al. 2012)

(Stokes and Mears 2000)

(Temple-Smith et al. 1999)

(Tsai and Hsiung 2003)

(Tsai 2004)

(Tsimtsiou et al. 2006)

(Vieira et al. 2015)

STDs (n = 8; 22%)

(Do et al. 2015)

(Khan et al. 2007)

(Khan et al. 2008)

(Maheux et al. 1995)

(McGrath et al. 2011)

(Tucker et al. 2012)

(Verhoeven et al. 2003)

(Webber et al. 2009)

Sexual dysfunction (n = 5; 14%)

(Abdolrasulnia et al. 2010)

(Goldstein et al. 2009)

(Humphery and Nazareth 2001)

(Platano et al. 2008)

(Ribeiro et al. 2014)

Sexuality and disease (n = 4; 11%)

(Byrne et al. 2013)

(Cort et al. 2001)

(Doherty et al. 2011)

(Oskay et al. 2014)

LGBTQ (n = 3; 8%)

(Hayes et al. 2015)

(Kitts 2010)

(Sanchez et al. 2006)

Multiple areas (n = 2; 6%)

(Barber et al. 2011)

(Wiggins et al. 2007)

Qualitative study (n = 11; 20%)

Multiple areas (n = 5; 46%)

(Carter et al. 2014)

(Collins 2006)

(Hinchliff et al. 2005)

(Stead et al. 2003)

(Wendt et al. 2011)

Sexuality and disease (n = 2; 18%)

(Hordern and Street 2007)

(Mellor et al. 2013)

Sexual health education/promotion (n = 2; 18%)

(Gott et al. 2004)

(Schweizer et al. 2013)

Sexual violence (n = 1; 9%)

(Leder et al. 1999)

STDs (n = 1; 9%)

(Woodbridge et al. 2015)

Intervention study (n = 6; 11%)

Sexual health education/promotion (n = 2; 33%)

(Cushing et al. 2005)

(Leeper et al. 2007)

STDs (n = 2; 33%)

(Lanier et al. 2014)

(Patel et al. 2009)

Sexuality and disease (n = 2; 33%)

(Quinn and Happell 2013)

(Quinn et al. 2013)

Literature review (n = 3; 5%)

Sexuality and disease (n = 1; 33%)

(Quinn and Happell 2013)

Sexual health education/promotion (n = 1; 33%)

(Kingsberg 2006)

STDs (n = 1; 33%)

(Emmanuel and Martinez 2011)


N.A.: Articles miscellaneous were classified as multiple areas.

For a more detailed outline of each of these 56 articles, please see our supplemental table (Table 5-4).


Table 5-4.
1995–2015 Peer-reviewed studies and methodologies related to health professionals’ facilitators and barriers in sexual history taking


















































































































































































Areasa

Author, year

Sample

Measures

Study design

Facilitators and barriers

Comments and commonalities

Sexual health education/promotion (n = 19)

(Ariffin et al. 2015)

N = 379, final-year medical students

Attitudes and perceptions regarding training on taking sexual histories

Cross-sectional survey

Barriers (1) feeling uncomfortable in taking sexual histories from patients, (2) cultural and religious differences between the doctor and the patient, (3) having received training not adequate to prepare doctors to take sexual histories

Participants reported high interest in sexual health and felt it was important for doctors to know how to take a sexual history. The delivery of sexual health education programme should incorporate confidence building and to make students feel comfortable to take sexual histories from patients

(Bouman and Arcelus 2001)

N[20;24], general consultant psychiatrists

Perceptions on taking a sexual history and management of sexual dysfunction

Cross-sectional survey

Barriers (1) conflicting attitudes and perceptions of the patients who rarely volunteer their symptoms, (2) difficulties of the psychiatrists in disconnecting from their own personal belief system regarding aged sexuality, (3) lack of awareness of physiological, pharmacological and psychosocial bases of sexual problems, (4) referral of middle-aged patient with sexual dysfunction to sexual therapy and elderly patients to community psychiatric nurses, (5) sexual therapy not included in the training schemes of community psychiatric nurses

Sexual history is often omitted in the psychiatric assessment of elderly men; elderly men with sexual dysfunction do not receive appropriate referral and treatment

(Bull et al. 1999)

N = 121 clinic sites, 208 service providers (physician extenders, nurses, nonclinical administrators, nursing or medical assistants or clerical staff)

Sexual history

Cross-sectional survey

Facilitators (1) good communication skills, (2) training and experience, (3) provider comfort

Barriers (1) client emotional response to sexual transmitted diseases (STDs), (2) lack of time, (3) client reluctance to talk about STDs, (4) client reluctance to change behaviour, (5) client resistance to discuss STDs

Practice patterns for the elicitation of sexual history were inconsistent. Sexual history taking was described as routine in 57% of sites

(Burd et al. 2006)

N = 78, physicians (obstetrician/gynaecologist—ob/gyns, family practitioners, internists, paediatricians and surgeons)

Discomfort during interviews

Cross-sectional survey

Barriers (Characteristics causing discomfort) (1) patient’s age <18 and >65, (2) patient’s academic achievement below college level, (3) patient’s marital status (divorced or single), (4) interviewing opposite gender patients

88% reported taking sexual histories; 13% reported asking about sexual dysfunction in every patient interview

(Cushing et al. 2005)

N = 192, medical students attending a workshop

Attitudes, behavioural intentions, behaviour (pre- and postworkshop evaluations)

Intervention study

Facilitators (By the end of the workshop) (1) students more likely to think they would initiate discussion of patients’ sexual problems and to think that patients want doctors to make such enquiries; (2) students more likely to think that sexual problems could be an issue for patients with serious illnesses such as gynaecological cancers, (3) students more likely to ask patients’ questions about sex in situations when it could be relevant

Attendance at the sexual health workshops or any one particular teaching session on sexual health was not a predictor of whether students asked patients about sexual health in subsequent clinical settings, but those students who had attended an additional teaching session were more likely to have done so. Predominantly it was in obstetrics and gynaecology or infectious disease clinical settings where students asked questions. A minority had asked such questions in general practice settings
 
(Dadich and Hosseinzadeh 2013)

N = 431 clinicians (214 general practitioners—GP—and 217 practice nurses)

Awareness, use and perceived impact of six resources to promote sexual health care: a placard that guides sexual health consultations, an interactive course, a face-to-face programme of active learning, an independent learning programme booklet, a practice nurse postcard to help practice nurses undertake a preventative women’s health check, an online interactive training course

Cross-sectional survey

Facilitators (1) six different resources were reported to improve the delivery of sexual health care, (2) the reorganization of the primary care sector, (3) the removal of particular medical benefits scheme items

Barriers (1) limited time, (2) limited perceived need, (3) limited access to and familiarity with the resources

The results highlight (1) the translation of evidence-based practices into patient care is viable despite reform, (2) the potential value of a multimodal approach; (3) the dissemination of relatively inexpensive resources might influence clinical practices, (4) reforms to governance and/or funding arrangements may widen the void between evidence-based practices and patient care

(Gott et al. 2004)

N = 22, GP working in demographically diverse primary care practices

Sex and sexual health in primary care: effect of patient age upon GPs’ management of sexual health issues

Qualitative study

Barriers (1) sexual health priorities within primary care not perceived as relevant to older people, (2) communication and training issues, (3) sex as “private” for older people and the risk of causing offence, (4) understandings of sexuality and old age

GPs do not address sexual health proactively with older people; sexual health is equated with younger people and not seen as a “legitimate” topic for discussion with this age group; beliefs are based on stereotyped views of ageing and sexuality, rather than personal experience of individual patients

(Jolley 2002)

Gynaecology nurses

Frequency of sexual history and barriers for taking sexual history

Cross-sectional survey

Facilitators (1) guidance on taking a sexual history

The results of the survey suggest that gynaecology nurses need clear guidelines and policies for sexual history taking, supported by education and training

(Kingsberg 2006)

Clinicians

Barriers for taking sexual history and assess current sexual function in women

Literature review

Barriers (1) insufficient medical education or training, (2) lack of confidence, (3) underestimation of sexual dysfunction prevalence, (4) time pressure, (5) few perceived treatment option, (6) patient discomfort

The importance of sexual health to a woman’s quality of life is often understated. The most effective treatment is to ask

(Leeper et al. 2007)

N = 92, medical students

Satisfaction with the course, content learned (sexual history taking skills)

Intervention study

Facilitators (1) knowledge on how to effectively apply different questions for different patient age groups and situations, (2) practice of exercises and feedback in the course, (3) role playing the discussion of difficult topics such as human immunodeficiency virus (HIV) with patients

Barriers (1) Deficiency in sexual history-taking education

The need of more information on legal aspects of reporting and minor confidentiality, sexual assault, information about taking a sexual history from children, the elderly and intravenous (IV) drug users was identified

(Morand et al. 2009)

N = 56, medical students and residents in a paediatric emergency department

Barriers to taking a sexual history

Cross-sectional survey

Barriers (1) young age of the patient (adolescent girls presenting to the emergency department with abdominal pain), (2) presence of the patient’s parents during the consultation, (3) unsubstantiated beliefs that the patient was chaste, (4) lack of training

The barriers to taking a sexual history in adolescent girls are multifaceted. Further training is needed to expose learners’ preconceived notions of sexuality as barriers to taking a sexual history, to provide practical methods for overcoming those barriers and to further instil in learners the importance of doing so
 
(Schweizer et al. 2013)

N = 30, gynaecologists

Approaching sexuality during gynaecological consultations, the place of sexuality during consultations and training in sexology

Qualitative study

Facilitators (1) keeping the discussion open, by offering, from the gynaecologist’s perspective, the opportunity for the patient to address sexuality; (2) training in sexology

Barriers (1) lack of tools, (2) a sense of modesty, (3) eroticization of the relationship

The decision to integrate questions relating to sexuality seems to depend on non-medical factors such as the personal experience, interest or gender of the doctor

The majority of interviewed gynaecologists claimed that they asked their patients if they had “pain during intercourse” or if they had “any concerns in that area”. Male gynaecologists asked questions relating to methods of contraception. Female gynaecologists asked questions relating to the patient’s relationships. Only gynaecologists trained in sexology widened the field of enquiry by asking if the patient felt pleasure during intercourse, or if the patient’s partner is a man or a woman

(Sobecki et al. 2012)

N = 1.154, practising ob/gyns

Practices of communication with patients about sex

Cross-sectional survey

Facilitators (1) Practising predominately gynaecology

Barriers (1) communication

63% reported routinely assessing patients’ sexual activities; 40% routinely asked about sexual problems. 28.5% asked about sexual satisfaction, 27.7% about sexual orientation/identity, 13.8% about pleasure with sexual activity (13.8%). A quarter of ob/gyns had expressed disapproval of patients’ sexual practices. There are areas for improvement in ob/gyn practices with respect to communication with patients about the comprehensive range of sexual matters that relate to women’s health. Ob/gyns’ comfort and willingness to discuss sexual identity and orientation with patients remains an important area for further research; improved care for women of sexual minority groups may require interventions tailored to the age and/or gender of the ob/gyn physician

(Stokes and Mears 2000)

N = 234, practice nurses

Reported practice and training in sexual health, attitudes towards sexual health, barriers to discussing sexual health with patients and training needs

Cross-sectional survey

Facilitators (1) Having received training

Barriers (1) lack of time (2) lack of training, (3) concern about not being able to cope with the issues raised

93% of practice nurses would attend a local training course in sexual health. Nurses were more comfortable discussing sexual health issues with female patients and teenagers than with male patients and those of different sexual orientations

(Temple-Smith et al. 1999)

N = 520, high activity GPs, under 65 years old

Clinical features of STDs, investigations, treatment, public health issues, epidemiology and demographic information

Cross-sectional survey

Facilitators (1) GPs’ feelings of confidence about taking a sexual history where the need to do so is obvious to the patient, (2) finding of an acceptable way of making the patient aware of the need for sexual history taking, (3) display of posters advertising the importance of sexual behaviour to the patient’s overall health and GPs asking the patient about this during the consultation

Barriers (1) patient’s embarrassment in discussing sexuality, (2) length of the standard first consultation which allows insufficient time to take a sexual history (sexual topics are often raised by patients towards the end of a consultation), (3) lack of training, (4) infrequent STD consultations, (5) GPs’ lack of confidence in discussing this issues

The importance of educating both patients and GPs about sexual history taking is discussed
 
(Tsai 2004)

N = 391, nurses

Perceived facilitators and barriers nurses encounter when taking a sexual history

Cross-sectional survey

Facilitators (1) nurse’s desire to know whether or not a patient’s sexual history was related to his/her illness, (2) patient specifically mentioned a sexual problem, (3) having a bachelor of science or master’s degree in nursing, (4) having experience in taking a sexual history lead to higher perceived facilitators and lower perceived barriers

Barriers (1) patients’ feeling of embarrassment about the issues of sexuality, (2) sexuality unrelated to the treatment, (2) lack of professionals for referral of patients for further consultations

88.2% of the nurses had not attended any formal course about human sexuality. Half of the participants reported having taken a sexual history

(Tsai and Hsiung 2003)

N = 206, aboriginal nurses

Facilitators and barriers to sexual history taking

Cross-sectional survey

Facilitators (1) have attended a communication training course, (2) have experienced a needle stick accident (they want to prevent themselves or colleagues from becoming infected)

Barriers (1) patients’ feelings of embarrassed and not knowing how to answer the questions, (2) purposely concealing of information on the part of patients

Decreasing barriers and reinforcing facilitators about taking a sexual history are an important task for nursing education, and nurses can play an important role in promoting aborigines’ sexual health and decreasing the prevalence of STDs in this population

(Tsimtsiou et al. 2006)

N = 316, physicians participating in educational courses on erectile dysfunction

Involvement in taking sexual histories, patient–practitioner orientation scale (beliefs about the doctor–patient relationship), Physician Belief Scale (psychosocial aspects of patient care), Derogatis Sexual Functioning Inventory (sexual attitudes)

Cross-sectional survey

Facilitators (1) previous training in communication skills, (2) medical specialty (possibly reflecting level of education in sexual medicine), (3) having liberal sexual attitudes, (4) physicians in private practice, (5) physicians addressing patients’ psychosocial concerns

Barriers (1) female physicians and GPs reported more difficulty in dealing with sexual problems

Physicians’ training in communication skills seems to be fundamental for sexual history taking and the management of sexual problems, as it improves their level of comfort in dealing with sexual issues; exposure to sexual medicine courses and psychosocial orientation, as well as physicians’ personal sexual attitudes, are also important factors affecting their involvement in sexual medicine

(Vieira et al. 2015)

N = 197, obstetrician and gynaecologist residents enrolling in an online sexology course

Training in sexuality during medical school and residency and attitudes and practice on sexual issues during pregnancy

Cross-sectional survey

Barriers (1) lack/few hours of training about sexuality in medical school, (2) lack/few hours of formal training about sexuality during residency up to that moment, (3) feeling of incompetence and lack of confidence to answer pregnant patients’ questions about sexuality, (4) lack of specific knowledge on the topic

Almost two-thirds of the participants stated that they did not receive any training at all about sexuality in medical school

STDs (n = 12)

(Do et al. 2015)

N = 371, physicians

Frequency of sexual history and barriers for taking sexual history among female sex workers (FSW)

Cross-sectional survey

Facilitators Factors associated with always taking a sexual history (1) being doctor, (2) training in STIs, (3) working at provincial level facilities. Factors inversely associated with physician’s discomfort (1) Training on communication with patients, (2) seeing 15 or fewer patients a week, (3) working at provincial level facilities

Barriers (1) physicians’ and patients’ discomfort (2) time constraints

27% respondents always obtained and 19% respondents never obtained a sexual history from FSW patients. Improvements in sexual history taking in general practice require strategies to improve physicians’ knowledge, skills and attitude towards sexual history taking from FSW and other at risk groups. Tools that allow physicians to quickly and comprehensively obtain patients’ sexual history and empower FSW to be more proactive about their sexual health are also needed

(Emmanuel and Martinez 2011)

Physicians (mainly paediatricians)

Epidemiological data about routine HIV screening

Literature review

Barriers (to routine HIV testing) (1) physicians’ lack of knowledge with local laws (concerning consent and confidentiality for HIV care and treatment that vary among states), (2) reimbursement and disclosure to parents via insurance billing, (3) lack of knowledge with regard to available resources for referral in communities

Paediatricians can play a key role in preventing and controlling HIV infection by promoting risk-reduction counselling and offering routine HIV testing to adolescent and young adult patients

(Khan et al. 2007)

N = 409, GPs

Sexual risk assessment and barriers in eliciting sexual histories from patients

Cross-sectional survey

Facilitators (1) further training in sexual history taking

Barriers (1) lack of time, (2) a concern that patients might feel uncomfortable if a sexual history was taken, (3) the presence of another person in the consultation room, (4) physician’s embarrassment

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