Developed by Sarit A. Golub, PhD, MPH, Hunter College and Graduate Center, City University of New York, in collaboration with the NYC Department of Health and Mental Hygiene, Bureau of HIV, July 2019
Background: Sexual history taking can be an onerous and awkward task that does not always provide accurate or useful information for patient care. Standard risk assessment questions (e.g., How many partners have you had sex within the last 6 months?; How many times did you have receptive anal sex with a man when he did not use a condom?) may be alienating to patients, discourage honest disclosure, and communicate that the number of partners or acts is the only component of sexual risk and health.
In contrast, the GOALS framework is designed to streamline sexual history conversations and elicit information most useful for identifying an appropriate clinical course of action.
The GOALS framework was developed in response to 4 key findings from the sexual health research literature:
- Universal HIV/STI screening and biomedical prevention education is more beneficial and cost-effective than risk-based screening [Wimberly, et al. 2006; Hoots, et al. 2016; Owusu-Edusei, et al. 2016; Hull, et al. 2017; Lancki, et al. 2018].
- Emphasizing benefits—rather than risks—is more successful in motivating patients toward prevention and care behavior [Weinstein and Klein 1995; Schuz, et al. 2013; Sheeran, et al. 2014].
- Positive interactions with healthcare providers promote engagement in prevention and care [Bakken, et al. 2000; Alexander, et al. 2012; Flickinger, et al. 2013].
- Patients want their healthcare providers to talk with them about sexual health [Marwick 1999; Ryan, et al. 2018].
Rather than seeing sexual history taking as a means to an end, the GOALS framework considers the sexual history taking process as an intervention that will:
- Increase rates of routine HIV/STI screening;
- Increase rates of universal biomedical prevention and contraceptive education;
- Increase patients’ motivation for and commitment to sexual health behavior; and
- Enhance the patient-care provider relationship, making it a lever for sexual health specifically and overall health and wellness in general.
The GOALS framework includes 5 steps:
- Give a preamble that emphasizes sexual health. The healthcare provider briefly introduces the sexual history in a way that de-emphasizes a focus on risk, normalizes sexuality as part of routine healthcare, and opens the door for the patient’s questions.
- Offer opt-out HIV/STI testing and information. The healthcare provider tells the patient that they test everyone for HIV and STIs, normalizing both testing and HIV and STI concerns.
- Ask an open-ended question. The healthcare provider starts the sexual history taking with an open-ended question that allows them to identify the aspects of sexual health that are most important to the patient, while allowing them to hear (and then mirror) the language that the patient uses to describe their body, partner(s), and sexual behaviors.
- Listen for relevant information and fill in the blanks. The healthcare provider asks more pointed questions to elicit information that might be needed for clinical decision-making (e.g., 3-site versus genital-only testing), but these questions are restricted to specific, necessary information. For instance, if a patient has already disclosed that he is a gay man with more than 1 partner, there is no need to ask about the total number of partners or their HIV status in order to recommend STI/HIV testing and PrEP education.
- Suggest a course of action. Consistent with opt-out testing, the healthcare provider offers all patients HIV testing, 3-site STI testing, PrEP education, and contraceptive counseling, unless any of this testing is specifically contraindicated by the sexual history. Rather than focusing on any risk behaviors the patient may be engaging in, this step focuses specifically on the benefits of engaging in prevention behaviors, such as exerting greater control over one’s sex life and sexual health and decreasing anxiety about potential transmission.
Resources for implementation:
- Script, rationale, and goals: Box 1, below, provides a suggested script for each step in the GOALS framework, along with the specific rationale for that step and the goal it is designed to accomplish.
- The 5Ps model for sexual history-taking (CDC): Note that the GOALS framework is not designed to completely replace the 5Ps model (partners, practices, protection from STI, past history of STI, prevention of pregnancy); instead, it provides a framework for identifying information related to the 5Ps that improves patient-care provider communication, reduces the likelihood of bias or missed opportunities, and enhances patients’ motivation for prevention and sexual health behavior.
|Box 1: GOALS Framework for the Sexual History
|Component||Suggested Script||Rationale and Goal Accomplished|
|Give a preamble that emphasizes sexual health.||I’d like to talk with you for a couple of minutes about your sexuality and sexual health. I talk to all of my patients about sexual health, because it’s such an important part of overall health. Some of my patients have questions or concerns about their sexual health, so I want to make sure I understand what your questions or concerns might be and provide whatever information or other help you might need.||
|Offer opt-out HIV/STI testing and information.||First, I like to test all my patients for HIV and other sexually transmitted infections. Do you have any concerns about that?||
|Ask an open-ended question.||
Pick one (or use an open-ended question that you prefer):
|Listen for relevant information and probe to fill in the blanks.||
|Suggest a course of action.||
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