What components should be included when taking a comprehensive sexual history in psychiatry for a patient with a previous psychiatric diagnosis and potential sexual health concerns?

Comprehensive Sexual History in Psychiatry

A comprehensive sexual history in psychiatry must include trauma-informed inquiry about sexual assault/unwanted sexual activity, current sexual function and satisfaction, relationship dynamics, medication effects on sexual function, gender identity and sexual orientation, and specific psychiatric symptom impacts on sexuality. 1, 2

Essential Components to Address

Trauma and Safety Assessment

• Directly ask about any history of unwanted sexual activity or sexual assault using trauma-informed language, as sexual violence significantly increases risk for depression, suicidality, self-harm, sexually transmitted infections, and chronic pain syndromes 1, 3
• Screen for current suicidal ideation, self-harm behaviors, and safety concerns related to perpetrators at every encounter 4, 3
• Recognize that transgender and gender-diverse patients experience sexual assault at higher rates than cisgender persons, requiring particular sensitivity 1

Sexual Function Status Examination

• Use explicit language to obtain detailed information about the chief sexual complaint, including frequency, duration, relationship to specific partners, and degree of distress caused 1, 2
• Assess all phases of sexual response: desire/libido, arousal, orgasm, satisfaction, and any pain or discomfort 1, 2
• Inquire about frequency and nature of sexual activity (foreplay, masturbation, intercourse, use of visual stimuli) and aggravating or alleviating factors 1, 2
• For patients with sexual orientation obsessions, assess time occupied by obsessive thoughts, interference from obsessions, distress level, and avoidance behaviors, as 21% report suicidal levels of distress 1

Medication and Psychiatric Symptom Impact

• Review all current medications and their potential sexual side effects, as most antidepressants (except bupropion, agomelatine, mirtazapine, vortioxetine, amineptine, and moclobemide) cause sexual dysfunction 5
• SSRIs particularly delay ejaculation and female orgasm, decrease libido, and cause erectile difficulties in a dose-dependent, usually reversible manner 5
• Assess how psychiatric symptoms (psychosis, hallucinations, anhedonia, mood changes) interfere with interpersonal and sexual relationships 5
• Document relationship between substance use/abuse and sexual function 1, 2

Gender Identity and Sexual Orientation

• Document gender identity (separate from sexual orientation), gender assigned at birth, affirmed name, pronouns, and organ inventory in the medical record 1, 6
• Use patient-determined name and pronouns consistently throughout all interactions 4, 6
• Inquire about genital dysphoria, genital tucking practices, and how gender dysphoria affects sexual function and relationships 1, 4
• Recognize that delaying gender-affirming care (including hormone therapy) due to psychiatric symptoms significantly worsens mental health outcomes and gender dysphoria 4

Relationship and Psychosocial Context

• Assess quality of personal relationships, partner satisfaction, and impact of sexual problems on relationships 1, 2
• Define "family" inclusively to include those with ongoing emotional relationships regardless of legal or biological ties 6
• Evaluate psychological factors including fear, anxiety, depression, and relationship to sexual activity 1, 5
• Document family and psychosexual developmental history 2

Medical Comorbidities

• Review medical history for conditions associated with sexual dysfunction: diabetes, hypertension, cardiovascular disease, neurological conditions 1, 2
• For cancer survivors, assess impact of surgery, radiation, chemotherapy, and hormonal agents on sexual function 1
• Obtain relevant physical examination findings and laboratory tests only when indicated by history 1, 2

Critical Communication Strategies

Initiating the Discussion

• Take the initiative to discuss sexual health—patients rarely volunteer this information spontaneously 5, 7
• Use open-ended questions initially, allowing expansion based on patient responses 8, 9
• Create a calm, private environment and maintain a nonjudgmental, sensitive approach to reduce patient anxiety 3, 8, 9
• Normalize the discussion by explaining that sexual health is a fundamental quality-of-life issue routinely addressed in comprehensive psychiatric care 7

Timing and Individualization

• Assess whether the patient had sexual activity before psychiatric illness to determine relevance of sexual counseling 1
• Some patients prefer discussing sexual issues during hospitalization, others after returning to routine—assess individual preference 1
• Respect patient privacy while balancing the need for education and support 1

Common Pitfalls to Avoid

• Never assume patients will spontaneously report sexual problems—clinicians must proactively inquire 5, 7
• Never conflate gender identity with sexual orientation—these are fundamentally different constructs requiring separate assessment 6
• Never delay gender-affirming hormone therapy due to psychiatric symptoms, as this worsens outcomes 4
• Never assume older patients or those with severe psychiatric illness lack interest in sexuality 8, 7
• Never use interpretive or value-laden language—use exact, objective descriptions 3
• Never fail to document findings thoroughly, as medical records may be subpoenaed for legal proceedings in trauma cases 3

Documentation Requirements

• Include sexual orientation and gender identity as standard components of the psychiatric record 6
• Document organ inventory, preferred name, and pronouns in accessible fields that all providers can view 1, 6
• Use validated screening instruments when appropriate (Brief Sexual Symptom Checklist for women, SHIM or IIEF for men) 1