How you phrase questions when obtaining a sexual history can mitigate the impact of social desirability bias and enhance the accuracy of the information that is obtained.
I have taken care of patients with sexually transmitted infections for the past twenty years. Getting an honest unbiased sexual history is of paramount importance as it directly impacts the quality of care that I can provide. I’ve distilled two principles from my experiences in sexual history-taking:
1.) Patients don’t want to lie to me about their sexual behaviors.
2.) Patients will tell me what they think I want to hear.
The second principle often trumps the first – as a consequence, patients may lie to me. This second principle simply reflects social desirability bias – a tendency to provide information that will be viewed favorably by others. Social desirability bias can significantly hinder our ability to gather reliable information to guide our management of patients.
Minimizing social desirability bias
I’ve often asked myself what I can do to minimize the impact of social desirability bias. How can I make it clear to them that no matter the information they provide, I will not judge them, nor stop caring for them (“I don’t care about what you’re doing and with whom you’re doing it, I just care about you. To best take care of you, I need you to answer my questions honestly”)?
The importance of continuity of care
I have found that a relationship that develops as a result of continuity of care is most helpful in mitigating the impact of social desirability bias. Over time, by modeling a consistent caring and nonjudgmental attitude, I’ve found that the impact of social desirability bias tends to diminish (“doc, I feel like I can tell you anything”).
Thoughtful wording of questions
However, we’re often meeting patients for the very first time and we need honest answers to sensitive questions. I’ve found that, in addition to body language, the wording of questions can have a significant impact on minimizing social desirability bias.
Let me illustrate this with a few examples:
When asking about the gender of my patient’s sex partners, I prefer to ask, “Are your partners male, female, or both male and female?” This is better than, “Do you have same sex partners?” or, “Do you have sex with men/women?”
When asking about condom use, I ask, “Do you often use condoms when you have sex?” This is better than, “Do you (always) use condoms when you have sex?”
Patients who always use condoms will tell me so, and patients who often use condoms, by definition, don’t always use them. Thus, those who do not always use condoms find it easier to admit to that socially undesirable behavior when the latter question format is used.
Practice makes perfect
Many clinicians feel awkward about obtaining a sexual history. They need to get over it because patients trust us with their health and we’ve made a commitment to honor that trust. The best way to get over it is to do it consistently in all patients. I guarantee that the feeling of awkwardness will dissipate within a week. I urge all clinicians to commit to an approach that mitigates social desirability bias, to practice that approach, and to implement it in all their patient encounters. Our patients deserve nothing less.