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Male adolescents experience adverse sexual/reproductive health (SRH) outcomes, yet few providers deliver male SRH care. Given the lack of evidence base for male SRH care, the purpose of this study was to examine perceived importance in delivering SRH care to male adolescents among clinicians focused on male health.
Seventeen primary care clinicians focused on male health, representing pediatricians, family physicians, internists, and nurse practitioners, were individually queried about male adolescents’ SRH needs and perceived importance to screen/assess for 13 male SRH services using a case-scenario approach varying by visit type and allotted time.
Participants were highly consistent in identifying a scope of 10 SRH services to deliver to male adolescents during a longer annual visit and a core set of 6 SRH services during a shorter annual visit including 1) counseling on sexually transmitted infection/human immunodeficiency (STI/HIV) risk reduction including testing/treatment; and assessing for 2) pubertal growth/development; 3) substance abuse/mental health; 4) non-STI/HIV genital abnormalities; 5) physical/sexual abuse; and 6) male pregnancy prevention methods. Participants did not agree whether SRH care should be delivered during non-annual acute visits.
Despite lack of data for male SRH care, clinicians focused on male health strongly agreed upon male SRH care to deliver during annual visits that varied by visit type and allotted time. Study findings provide a foundation for much needed clinical guidelines for male adolescents’ SRH care and have implications for education and training health professionals at all levels and the organization and delivery of male SRH services.
Managing the health of populations is increasingly the focus of the U.S. healthcare system especially when addressing sexual/reproductive health (SRH) morbidity and mortality. However, male adolescents’ SRH, among a population that is typically considered to be “healthy”, is one area of healthcare that has historically received little attention. Male adolescents have significant unmet SRH needs including issues related to pubertal and sexual maturation, sexual identity, and sexual behavior. Providing evidence-based and effective SRH care to male adolescents is one important way to reduce adverse SRH outcomes including sexually transmitted infections (STIs),1 human immunodeficiency (HIV),2 unintended pregnancy,3 teen parenthood,4 and reproductive health-related cancers.5
Information about effective SRH care to deliver to male adolescents is lacking due in large part to a limited evidence base of studies examining SRH-related matters among this population. This limits the ability of organizations relying on evidence, such as the U.S. Preventive Services Task Force (USPSTF),6 to make specific SRH care recommendations for male-specific SRH services. Organizations such as the World Health Organization define SRH broadly and as preventing more than just STIs/HIV and unintended pregnancy including preventing reproductive health-related cancers; promoting sexual health and development, healthy intimate relationships and responsible behavior; and addressing issues related to sexual function and transitions in the SRH life course.7, 8 However, these organizations do not outline SRH care for delivery to male adolescents in clinical settings.
One challenge to organizing SRH care for males is that no one organization makes specific SRH care recommendations for males as is done for females.9 Recommendations by the USPSTF focus on single services; it is not the goal of the USPSTF to organize or bundle services for a clinical area. Although Bright Futures makes comprehensive recommendations designed to improve the health and well-being of all children and adolescents,10 Bright Futures’ recommendations are extensive, lack specificity for male-specific SRH care and do not prioritize promoted services for delivery to male adolescents. Secondary to these issues, professional organizations lack agreement in SRH care recommendations to deliver to male adolescents which can be confusing for primary care providers, including pediatricians, family physicians, internists and nurse practitioners, who serve the majority of this population and are thus ideally positioned to deliver SRH care to male adolescents.11–13 This may explain, in part, why few providers are found to deliver SRH care to male adolescents, including sexual health assessment, counseling on pregnancy, contraception and condoms, and STI/HIV testing.14–16 However, male adolescents cite their primary care provider as an important resource for sexual health and prefer providers to initiate discussions on sex and offer more information about sex, STIs, pregnancy and relationships.17, 18 Furthermore, Healthy People 2020 calls for increasing the proportion of sexually active males who report receiving reproductive healthcare including birth control advice or counseling about male or female methods of birth control or advice on sterilization, STIs, or HIV.19
A prerequisite for developing clinical practice guidelines is that they should be systematically developed and based on the best available evidence.20 However, when high-quality evidence is absent there are limited alternative methods to inform guideline development. Consensus methods engaging experts is one approach that is often used when high-quality evidence in the published literature is lacking.21 Although expert opinion is considered to be on the lower end of the evidence ladder,22 limitations to the merit and usefulness of expert opinion can be improved when explicit and transparent procedures are used.23, 24 In the absence of strong evidence for male adolescents’ SRH care,25 expert opinion has an important role in identifying priority SRH services to deliver to this population. Thus, this paper’s primary objective is to examine whether there is consensus on SRH care to deliver to male adolescents among clinicians focused on male health.
In the context of primary care, recommendations for SRH care delivery to male adolescents may also need to take into account visit type and allotted time. For example, the majority of male adolescents (~75%) report having a routine physical examination and/or at least one sick visit with their primary provider in the past year26 and the majority of sexually active males report having at least one routine visit over a 2-year period.27 However, as male adolescents get older declines in routine visits are reported12, 28, 29 and providers more often offer preventive care to adolescents during acute than well visits.30 Visit length and thus lack of time can also limit providers’ delivery of clinical preventive services31 with average visit length for adolescent patients lasting about 16 minutes.28, 32 Thus, this paper’s secondary objective is to examine whether recommendations for SRH care delivery to male adolescents may need to account for visit type and allotted time.
This study used a mixed method approach for consensus building including semi-structured key informant interviews and quantitative survey research.
Clinicians focused on male SRH care were identified from lists of prior expert panels (n=8),8, 33 publication record on male SRH (n=7) and referral based on their history of working primarily with male adolescents in primary care (n=4). Clinicians were purposively chosen to be representative of primary care disciplines (i.e., pediatricians, family physicians, general internists and nurse practitioners) working in public and private settings from all regions of the U.S. (Table 1), inclusive of women providers and providers working with sexual minority populations. The process of selecting participants was nonrandom which is typical of activities seeking consensus opinion input.34 Although participants may not represent the diversity of community-based primary care providers, clinicians focused on male SRH care in the context of primary care were intentionally included because their practices, although not representative, might serve as a standard for SRH care delivery to males in primary care.
Potential participants were first contacted by email regarding their interest in participation. The email included a cover letter describing the study’s rationale and protocol, the study’s exempt human subjects review board status and the receipt of a US$50 stipend upon completing study activities. The final recruitment sample was chosen to limit informational redundancy – the point at which additional data do not contribute to new information.35
In Round 1, semi-structured, key informant, one-one-one telephone interviews were conducted with clinicians to generate a common list of SRH services. During interviews, each participant was asked to brainstorm SRH health needs for young men using free-listing. Free-listing is a common technique used by anthropologists to ensure all ideas are generated and explained by members of the study population themselves, particularly when a common list of information is not generally known.36 Specifically, participants were asked “to describe a male adolescent’s sexual/reproductive health needs” and to describe any additional needs for males who are “sexually active”; “not sexually active”; “on the brink of sexual activity”; “gay, bisexual or questioning”; and from “any group and/or category” not already mentioned. Follow-up probes were used (e.g. “Can you think of anything else”; “Please explain what you mean by…”) until no new responses were generated. Interviews lasted, on average, 50 minutes and were audio recorded and transcribed.
In Round 2, the same participants were contacted via email and asked to individually complete a brief survey instrument that assessed their perceived importance of delivering SRH services identified in the prior round to male adolescent patients. We used case scenarios to examine SRH service delivery variation based on visit type and allotted time:
After each scenario, participants were queried whether they would screen/assess for each SRH service. Participants were also asked about their perceptions of effective clinical strategies/treatments for each SRH service.
During Round 1, participants generated a mean (standard deviation [SD]) of 24.4 (4.9) items with a range of 15 to 33 items. Participants’ free-list responses were entered into a spreadsheet and then categorized. The principal investigator and a research assistant independently reviewed items and proposed categories, resulting in agreement the majority of the time (>95%). When not in agreement, items were discussed and a mutually agreed upon category was used. Using the developed categories, participants’ unique, non-repetitive responses were coded. Nineteen unique domains were identified (Table 2). SRH issues relevant for clinical care delivery identified by 8 or more participants were chosen for assessment in the brief survey instrument during the subsequent round (Table 3).
Participants’ responses from the brief survey instrument for each scenario were entered into SPSS. Descriptive analyses, including the generation of response frequencies, were performed by case-scenario (Table 3).
Among 20 potential participants, 17 responded and agreed to participate (85% participation rate). All clinicians who agreed to participate completed both study rounds (100% retention rate). On average, participants were an experienced group of clinicians (28 years in practice [SD=9]) who were primarily pediatricians (82%) working in public settings across the nation (82%). Participants reported seeing a mean number of 39 (SD=29) adolescents per week and 20 (SD=17) males per week. Participants’ reported time for a new patient visit was 35 minutes (SD=14), 27 minutes (SD=10.2) for an established visit and 17 minutes (SD=6) for an acute visit.
Overall, participants identified 19 unique SRH need areas for male adolescents. The majority of participants discussed needs related to female hormonal contraception (100%) and male birth control methods (88.2%), mental health and substance abuse issues (100%), normal growth and development (94.1%), sexual basics (94.1%), partner communication and responsibilities (94.1%), and specific SRH-related relationship issues (88.2%). The majority of participants also discussed needs related to cultural expectations about what it means to be a man (82.4%), STIs/HIV (82.4%), sexuality and sexual identity development (76.5%), parent/peer communication (64.7%), physical/sexual abuse (52.9%), non-STI related genital issues (47.1%) and transitions to adulthood (47.1%). Fewer participants discussed issues concerning pornography, female anatomy, fertility concerns, cultural expectations about the male body image and issues concerning confidentiality.
Some participants mentioned additional populations of male adolescents who may have additional and/or unique SRH needs. This included males with developmental delay, males from conservative and/or religious families, males who are detained, homeless, or recent immigrants involved with commercial sex work, or transgender.
Among the 13 clinically relevant services assessed in the brief follow-up survey, the majority of participants perceived it important to deliver 10 SRH services during the 40-minute annual physical examination. All participants (100%) perceived it important to deliver 5 services: 1) counseling on STI/HIV risk reduction inclusive of testing/treatment; 2) assessing/counseling on male-focused pregnancy prevention methods including condoms and abstinence; 3) screening for physical and sexual abuse; 4) screening for sexual identity/orientation; and 5) screening for substance abuse/mental health. All except one participant (94.1%) perceived it important to deliver 2 additional services: assessing for 6) pubertal growth/development and 7) relationship with sexual partner. Just over two-thirds of participants perceived it important to deliver additional services: 8) screening for genital abnormalities not inclusive of STIs/HIV (82.4%); 9) assessing for relationships with parents and peers (82.4%); and 10) assessing for transitions to adulthood (70.6%).
During the shorter, 15-minute annual visit, the majority of participants perceived it important to deliver 6 of 13 SRH services. All participants (100%) perceived it important to counsel on STI/HIV risk reduction inclusive of testing/treatment and all except one (94.1%) to screen for substance abuse/mental health and assess for pubertal growth/development. Just over two-thirds of participants perceived it important to screen for genital abnormalities not inclusive of STIs/HIV (76.5%); assess/counsel on male-focused pregnancy prevention methods (70.6%); and screen for physical and sexual abuse (70.6%).
As part of a 10-minute acute visit, for only 2 of the 13 SRH services did approximately half of the participants perceive it important to screen for substance abuse/mental health (47.1%) and counsel on STI/HIV risk reduction inclusive of testing/treatment (41.2%).
Among the 13 clinically relevant services assessed in the brief follow-up survey, all participants (100%) perceived effective strategies/treatments to be available for addressing sexual basics and relationships with parents and all except one participant (94.1%) perceived effective strategies/treatments to be available for genital abnormalities not inclusive of STIs/HIV. About two-thirds of participants perceived effective strategies/treatments to be available for sexual identity (64.7%), female-focused pregnancy prevention methods (76.5%) and substance abuse/mental health (70.6%). About half of participants perceived effective strategies/treatments to be available for STI/HIV risk reduction (52.9%), male-focused pregnancy prevention methods (47.1%), and relationships with sexual partners (58.8%).
Given the lack of evidence base for male adolescents’ SRH care25, in this first study to examine priorities for male adolescents’ SRH care, clinicians focused on male health care were highly consistent in SRH care they perceived to be important to deliver to male adolescents during an annual visit. Specifically, study participants’ identified a scope of 10 SRH care services to deliver to male adolescents during an annual visit regardless of visit length and perceived service effectiveness and a core set of 6 SRH care services for delivery during a shorter annual visit. Participants did not agree, however, whether SRH care should be delivered to male adolescents in the context of a non-annual acute visit. Until we have sufficient evidence from controlled trials, clinician opinion has an important role in the organization of SRH care to deliver to male adolescents in primary care and can contribute to the development of much needed guidelines for male-specific SRH care.
The scope of SRH care clinicians in this study perceived to be important to deliver to male adolescents in primary care is consistent with broader definitions of SRH as promoted by organizations such as the World Health Organization.7, 8 Participants were also highly consistent in the SRH care services they perceived to be important for male adolescents during annual visits regardless of visit length. This high level of consensus is reassuring because it can facilitate the development of future male-specific SRH care guidelines. It should not be a surprise that clinicians’ decisions regarding specific SRH care to deliver to male adolescents during annual visits varied by allotted time. Time is one of many factors shown to influence clinicians’ care delivery.37 Thus, future male adolescent SRH care guideline development may need to consider factors such as time to assist in the organization and delivery of SRH care to this population. Core SRH care clinicians’ perceived to be important when time is more limited included 1) assessing for pubertal growth and development; 2) counseling on STI/HIV risk reduction including testing and treatment; 3) assessing for mental health/substance abuse; 4) assessing for genital abnormalities not inclusive of STIs/HIV; 5) assessing for physical and sexual abuse; and 6) assessing for male-focused pregnancy prevention methods including condoms and abstinence. During longer annual visits if time is not limited, additional SRH care clinicians perceived to be important included assessing for sexual identity; relationships with partner, parents/peers; and transition to adulthood. Future work is needed to build the evidence base for the effectiveness of delivering these SRH services to male adolescents.
In this study, participants placed a greater emphasis on the importance of healthcare providers addressing bidirectional relationships between male adolescents’ SRH and development, mental health and substance use than guidelines such as Bright Futures. For example, clinicians perceived it important to screen male adolescents for substance abuse and mental health in the context of negative mental health consequences associated with initiating relationships and the course of dating; lack of condom use associated with substance use; and sexual dysfunction related to drug and medication use (e.g., alcohol, anti-depressants). Participants also emphasized the importance of providers meeting the SRH needs of sexual minority males (e.g., males who identify as gay and bisexual, who are questioning or who engage in sex with other males) especially as the needs relate to the coming out process and increased risk for substance abuse, depression and suicide. Participants’ emphasis on addressing sexual minority males’ needs is critical for a number of reasons. Historically, this population has been excluded from the SRH discourse that has focused primarily on involving males in pregnancy prevention and family planning. This is also a population for which clinicians report they are uncomfortable providing care38 and lack training.39 Together with SRH care clinicians’ perceived to be important, these findings have major implications for improving the current state of education and training that health professionals should receive at all levels on male adolescents’ SRH and healthcare.
Participants’ lack of consensus on whether SRH care should be delivered to male adolescents during acute visits is not consistent with other studies that report adolescent preventive services are sometimes delivered more often during acute rather than well visits.30 This may reflect changes in clinical practice, time pressures in the acute setting, or a combination of both. Given declines in health visits by males across adolescence and shifts from routine to more time-limited acute visits, interventions to improve SRH care delivery in the context of primary care should evaluate success of service delivery among visit types other than the annual visit including the acute care visit or male-focused SRH visits. For example, one system-based intervention in pediatric urgent care settings, designed to increase chlamydia screening among female adolescents, was found to be successful; screening significantly increased at experimental (from 23% at baseline to 48% 14-months later) compared to control sites (29% to 30%).40
This study has several potential limitations. First, the generated list of male adolescents’ SRH needs is dependent on the participants’ composition, active participation and ability to not overlook relevant SRH topics due to systematic or other reasons. In this study, each participant actively participated in both study phases, generated extensive lists of male adolescents’ SRH needs and yielded high consensus. Every effort was also made to be inclusive in the process of identifying a diverse sample of primary care clinicians who have a track record working with male adolescents on SRH-related matters, including female clinicians and clinicians working with sexual minority populations. Given participating clinicians’ focus on male health, future work should examine whether study findings hold among a more general sample of primary care providers. Second, although participants’ responses to case scenarios may differ from actual behaviors, it was the intention of this study to gain a better understanding of SRH care these clinicians perceived to be important to deliver to male adolescents. Third, consensus building methodologies may reflect conformity to panel recommendations rather than expression of one’s true opinion.24 However, participants in this study independently engaged in study activities, thus minimizing influences by other study participants. Fourth, this study did not examine clinical priorities for all SRH needs generated by experts (e.g., cultural expectations of what it means to be a man and male-body image and pornography) nor did not it examine a wide-range of influencing factors of SRH service delivery. Instead, the intention of this study was to describe clinicians’ perceptions of SRH care to deliver to male adolescents in primary care. Results from this study should not be viewed as independent recommendations but should provide a foundation for the development of much needed clinical guidelines for male adolescents’ SRH care. A major strength of this study is that it provides support for the benefit of consensus building methodology in addressing questions in an area of health that has otherwise been overlooked and currently lacks data to inform evidence-based recommendations for care.
Given the lack of evidence base for male adolescent SRH services, this study found clinicians focused on male health strongly agreed upon a core set of SRH care to deliver to this population during annual visits in primary care. Study findings provide a foundation for the development of much needed clinical guidelines for male adolescents’ SRH care, organization and delivery of male adolescents’ SRH care and education and training of health professionals at all levels. Study findings also have important implications given Healthy People 2020’s recent call to increase the proportion of sexually active males who receive SRH care. Future efforts should build an evidence base to support male adolescents’ SRH care, examine the extent to which core SRH services endorsed by participants in this study are currently being delivered by U.S. providers and whether training and system improvements can increase the proportion of male adolescents who receive these services.
Experts identified core SRH services to deliver to male adolescents during annual visit regardless of perceived service effectiveness and visit length. Findings provide a foundation for much needed clinical guidelines for male adolescents’ SRH care. Findings also help to organize a core set of SRH-related services to deliver to male adolescents in primary care and have implications for the education and training of health professionals at all levels.
The project described was supported by Grant Number K23HD47457 (Dr. Marcell) from the National Institute for Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute for Child Health and Human Development or the National Institutes of Health.Study sponsors were not involved in the study design, collection, analysis and interpretation of data, the writing of the report or in the decision to submit the manuscript for publication.
Participating clinicians included (listed alphabetically): Anthony Acquavella, MD, MPH, Temple University School of Medicine; Silvia Amesty, MD, MPH, MSEd, Columbia University; David Bell, MD, MPH, Columbia University; Frank Biro, MD, University of Cincinnati; Richard Brookman, MD, Virginia Commonwealth University; J. Dennis Fortenberry, MD, MS, Indiana University School of Medicine; Robert Garofalo, MD, MPH, Children’s Memorial Hospital Northwestern University; Joel J. Heidelbaugh, MD, University of Michigan Medical School; Robert L. Johnson, MD, FAAP, New Jersey Medical School; Linda Juszczak, DNSc, MPH, CPNP, National Assembly on School-Based Health Care; Paritosh Kaul, MD, University of Colorado School of Medicine; John Kulig, MD, Tufts University School of Medicine; Daryl A. Lynch, MD, FAAP, FSAM, University of Missouri School of Medicine; Erica Monasterio, MN, FNP-BC, University of California, San Francisco; Demetrius J. Porche, DNS, PhD, APRN, FAANP, FAAN, Louisiana State University Health Sciences Center School of Nursing; John Steever, MD, Mount Sinai Medical Center; and Charles J. Wibbelsman, MD, Kaiser Permanente, San Francisco, CA.
Portions of this paper were presented at the Society for Adolescent Health and Medicine annual conference in Seattle, WA, in 2011.
Conflict of Interest
Drs. Marcell and Ellen have no disclosures regarding any personal, commercial, political academic or financial interests. This includes no financial interests such as employment, research funding (received or pending), stock or share ownership, patents, payment for lectures or travel, consultancies, nonfinancial support, or any fiduciary interest in the company.
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