The 5 Ps need an update: toward a comprehensive sexual history

I would like to commend Van Ommen and colleagues1 for their informative review. I plan to distribute this article to colleagues and learners as a helpful practice tool.

As a reproductive and sexual health–focused family physician, medical educator and advocate, I also firmly believe in the importance of conducting a thorough sexual health history. However, I respectfully disagree with the suggested approach to taking a sexual history based on the 5 Ps, outlined by the US Centers for Disease Control and Prevention (CDC), as it fails to facilitate a comprehensive assessment. Although the CDC’s guide primarily aims to assist health care providers in assessing a patient’s risk of infection, I propose following an alternative approach put forth by the National Coalition for Sexual Health and supported by the CDC, in which the 5 Ps are modified and expanded to include the 3 additional Ps: pleasure, problems and pride.2 Incorporating these components into a sexual history ensures a more comprehensive, patient-centred and trauma-informed approach, and communicates to the patient that their provider cares about their sexual health beyond solely assessing their infection risk.

Furthermore, when asking about a patient’s partners, Table 1 suggests the questions, “What is/are the genders of your sexual partners?” and “Do your partners have other sexual partners? What is/are their gender(s)?” As health care providers, we have a responsibility to justify every question that we ask. Although these questions may help us gain a more nuanced understanding of a patient’s current sexual orientation and social context, they do not help capture essential information and may lead to false assumptions.

Gender refers to socially constructed roles, identities and expressions, and may not be aligned with a person’s assigned sex at birth or the sexual organs that they possess. 3 For example, learning that a patient’s partner identifies as a woman is of limited value. Conversely, understanding their partner’s sexual organ inventory or “parts” is essential to providing appropriate care. An open-ended question such as, “Who are your sexual partners?” or the statement, “Tell me about your sexual partners,” followed by a question such as, “Which of your partner’s body parts are involved when you have sex?” yields more medically accurate and actionable information.