© Springer International Publishing Switzerland 2016
Joel J. Heidelbaugh (ed.)Men’s Health in Primary CareCurrent Clinical Practice10.1007/978-3-319-26091-4_66. Caring for the Adolescent Male
(1)
Columbia University Medical Center, New York, NY, USA
(2)
Partnership for Male Youth, Washington, DC, USA
Introduction
Older adolescent and young adult (AYA) males have traditionally been left out/ignored in our healthcare system that primarily focuses on tertiary care [1]. AYA males are commonly defined as males between the ages of 10 and 24 [2]. As our healthcare system embarks on tasks of early prevention and improving the health of populations, greater attention will need to be paid to the “state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” as defined by the World Health Organization [3]. This holistic definition extends beyond the scope of the traditional pathology-focused Western tradition of medicine. For AYA males, social well-being and disease are, in fact, inseparable. The first half of this chapter will provide an overview of the major causes of mortality and morbidity in AYA males, discuss the barriers AYA males face in seeking and utilizing healthcare, and discuss the interplay of masculinity, health, and healthcare utilization. In the second half of this chapter, we will address ways of engaging males, despite these barriers, by constructing a vision of “AYA male-centered healthcare.”
Mortality
Mortality increases rapidly across adolescence. The United States of America (USA) has the sixth highest adolescent male mortality rate among high-income countries [4, 5]. Compared with females, males in high-income countries such as the USA are more likely to die of all major causes of mortality. The dominant cause of injury deaths among young men was transport injuries worldwide [5]. Although males have seen marked improvements in healthcare outcomes over the past 20 years, their mortality remains unacceptably high [5]. In the USA, the top three causes of death for males 10–24 years old are caused by unintentional injuries, homicide, and suicide [6]. Unintentional injury alone, which includes motor vehicle injuries, unintentional poisoning and drug overdose, drowning, and unintentional discharge of a firearm, account for 75 % of all mortality. Motor vehicle injuries account for the majority (71 %) of all unintentional injuries [4].
Morbidity
Chronic Illness
Reducing preventable chronic diseases is dependent on reducing alcohol, drug, and tobacco abuse, decreasing obesity, and increasing physical activity. Forty-six percent of high school males report having ever smoked a cigarette versus 43 % of high school females, and 12 % of males started smoking before age 13 versus 8 % of females [7]. The prevalence of obesity is 20 % among high school males and is rising compared to a stabilized rate of 17 % among high school females [8]. However, 38.8 % of males report 60 min of daily exercise compared to only 18.5 % of females [9].
Mental Health
AYA males are at high risk for depression. According to the 2013 Youth Risk Behavior Survey (YRBS), 30 % of high school students experienced some disruption of daily activity due to feeling sad or hopeless continuously for 2 or more weeks in a row. Among other mental health disorders that affect young males are anxiety disorders, attention deficit hyperactivity disorder (ADHD), psychotic disorders, bipolar and related disorders, obsessive compulsive disorder, and oppositional defiant disorder [10]. Although rates of depression and suicidal ideation are higher among females than males in adolescence and young adulthood, males are more likely to complete suicide. Depression is twice as common in women [11]. Men are three times more likely to die by suicide than women [12].
Substance Use
AYA males have higher substance abuse rates than females, and boys under 17 drink alcohol more heavily than any other population group. Among high school males, 39.5 % report any alcohol use in the past 30 days, and 23.8 % report consuming more than 5 drinks [13]. In 2011, among 9th through 12th grade students, males were more likely than females to use ecstasy, heroin, methamphetamines, hallucinogenic drugs, anabolic steroids, or illegal needle-injected drugs. Males were also more likely to be offered, sold, or given an illegal drug on school property. Drug use is exceedingly common, with 25.9 % reporting marijuana use in the past 30 days, 10.5 % inhalant use, and 9.8 % ecstasy use. Males are more likely to use cocaine than females, with 7.9 % of males reporting having ever used cocaine, as compared to 5.7 % of females. Current use of cocaine (used once or more in the past 30 days) is higher among males (4.1 %) than females (1.8 %). Males are more likely to use heroin than females, with 3.9 % of males reporting having ever used heroin, as compared to 1.8 % of females [7, 13]. In 2011, 21.5 % of adolescent males engaged in prescription drug use (e.g., oxycodone, hydrocodone, benzodiazepines) [14]. The majority (80 %) current heroin users report that their opioid use began with opioid pain relievers [15]. However, heroin users were far more likely to start with prior nonmedical pain reliever, according to one study [16].
Sexual Health Risks
In our risk-based health models based on pregnancy prevention, we traditionally begin our thoughts about sexual health risks (SHR) with the debut of heterosexual intercourse. Between 1998 and 2002, young males on average delayed their age of sexual debut. As of 2013, the median age has remained relatively consistent between 17 and 18 years of age since 2002 [19]. Current best estimates of sexual orientation in male youth reveal that 3 % of young males identify as homosexual or bisexual and 4 % report same-sex sexual behaviors [20]. While sexual behavior with same-sex partners can be an expression of sexual orientation (e.g., homosexual or bisexual), they are not equivalent [21]. Sexual encounters with same-sex partners, especially in adolescence and young adulthood, may represent experimentation and exploration.
There are documented risks associated with early sexual debut, unprotected sex, and sexual encounters with same-sex partners. A young age of onset of sexual behavior is associated with increased rates of sexually transmitted infections (STIs), early fatherhood, and sexual coercion. Early fatherhood is common, with 15 % of males fathering a child before age 20 [22]. AYA males also bear a disproportionate share of STIs relative to other age groups. In a national sample of 18- to 22-year-olds, 3.7 % were infected with Chlamydia trachomatis, 1.7 % with Trichomonas, and 0.4 % with Neisseria gonorrhoeae [23, 24]. Sexual behavior with same-sex partners is associated with higher sexual health risk.
Compared to men who have sex with women, rates of HIV and syphilis are higher among men who have sex with men (MSM) [25, 26]. MSM account for the largest numbers of new HIV infections, and African American MSM are the only group with increasing rates of HIV infection in the USA [27, 28]. Sexual orientation (e.g., identification with the LGBT ((lesbian, gay, bisexual, transgender) community) is associated with an increased risk for a much larger set of physical, mental, and social problems which impact health, including depression, suicidal ideation and behavior, homelessness, familial rejection, dropping out of school, substance abuse, STIs, and victimization [29]. Although equally important to understand the issues of LGBT youth, this chapter will focus on males, in general, inclusive, but not specific to MSM which will be covered in a later chapter.
Complexities and Barriers of Care for AYA Males
Many efforts toward prevention of disease do not require healthcare access. To date, we do not have proven in-office clinical interventions for many of the specific conditions that we aspire to prevent. The true value of the annual physical exam has also been questioned [30]. However, understanding how AYA males interact with the healthcare system currently, why they do and do not interact, and the reasons why we should and how we could strive to engage them in the healthcare system reveals a complex picture.
Lack of Health Service Infrastructure for Males
As boys transition out of childhood and into adolescence, their visits to primary care providers begin to decline. By mid to late adolescence, boys stop visiting their childhood physicians, which results in increasingly low rates of primary care visits [31]. In contrast, for girls, this transition is marked by their first visit to the gynecologist or primary care physician. This first visit traditionally involved their first annual Pap smears for cervical cancer screening. With newer guidelines emerging over the past decade that recommend initial Pap smears at the age of 21, we may start to see changing rates. However, without other policy or guideline changes, a broad range of services still exist that are specifically geared toward women’s health, strengthening this connection of women to health services. Included among these are the US-centric physician-regulated pregnancy prevention services—access to contraception—as well as other SHR screening.
Males do not have a comparable connection to the health system that promotes utilization of services in this transitional period of their life. Among both male and female 12–17-year-olds, less than half receive the recommended yearly preventive care visits [32]. As compared to females, young adult males are less likely to have a usual source of healthcare (63 % vs. 78 %), are less likely to have visited a doctor in the past year (59 % vs. 81 %), and are less likely to have visited the emergency department within the last year (19 % vs. 27 %) [31, 33–35]. The lack of knowledgeable clinicians engaged in caring for the AYA males; the lack of clear clinical guidelines for AYA males, including routine STI screening as we have for women for chlamydia; and the common lack of insurance coverage for this age group are commonly stated systemic factors for low rates of preventive service utilization by AYA males [36–38]. We will discuss the latter two factors further.
Despite guidelines that include preventive services for AYA males—the American Medical Association’s Guidelines for Adolescent Preventive Services (GAPS) [39] and Bright Futures [40]—the counseling of male teenagers, particularly around the prevention of sexually transmitted infections (STIs) or HIV infection, still warrant significant improvement [37, 41]. Primary care providers take male sexual histories three times less often than female sexual histories and counsel males two times less than females on the use of condoms [42]. The USPSTF does not recommend STI screening for men who are not at increased risk [43]. The USPSTF recommends HIV and syphilis screening for men engaging in high-risk sexual behavior. Additionally, because of significant geographic and community variation, physicians should consider the risk in the community and populations they serve when making decisions about screening men for syphilis [43]. Despite the fact that Chlamydia infections are common and curable, the clearest guidelines for the frequency of screening exist for heterosexual women, but not for heterosexual men [44].
Young adults represent the age group with lowest health insurance coverage rates, with young adult males having lower rates than their female counterparts [31, 33, 45, 46]. The passage of the Affordable Care Act in 2010 and the accompanying expansion of dependent coverage may lead to advances in AYA male coverage [46]. However, coverage rates and associated health service utilization rates among young males remain unacceptably low.
Masculinities
Masculinity may be defined as, “a set of culturally shared beliefs about how men should and should not present themselves” [47]. It is a complex and socially guided set of activities that represent what it means to be a man [48]. Dominant masculine norms tend to stress independence, strength, autonomy, and emotional stoicism [49]. Current scholars of masculinity suggest that masculine behaviors are “neither biologically determined nor unique,” but, rather, learned through social interactions that begin early in life and continue through adult life [50–52]. Adolescent and young adult years offer increasingly salient opportunities to “try” masculine gender norms and incorporate them or challenge them [36, 48, 49, 53]. However, research on masculinity suggests that there may not be any one dominant or homogenous masculine gender norm, but instead a complex spectrum of masculinities [54].
Of considerable concern in adolescent male health is the frequent and increasing disconnect from healthcare associated with exposure to masculine gender norms over the period of adolescence [55]. Taken together, the dominant cultural view of masculinity and the individual expressions of masculinity make masculinity both a systemic and an individual factor in the health-seeking behaviors by males. Strong adherence to the dominant masculine ideals is associated with less care-seeking behaviors [53, 55]. With hegemonic masculine gender norms stressing autonomy, strength, and self-reliance, many young males see health-seeking behaviors as incongruent with what it means to be a man [36, 55]. This disconnect between young males and the healthcare system represents a missed opportunity to provide them with the support and care that they need during this transitional period of their lives [55]. Subscription to masculine beliefs among AYA males has been associated with poor sexual health outcomes, poorer mental health outcomes, and lower health service utilization [52, 53, 55, 56].
The relationship between the subscription to dominant masculine beliefs with poorer mental health outcomes must be underscored. Poor mental health outcomes are most likely related to increased subscription to anger, as the most commonly expressed emotion, which likely leads to injury, particularly violence to the other or to the self. In other words, it is likely that our top three causes of mortality are mediated through masculinity’s emotional lens. Many young males use emotional stoicism and acting tough and stereotypical masculine feelings and behaviors, as the only coping strategy available to them. Furthermore compounding the issue, the proscribed stoicism limits adolescent and young males’ willingness to share their concerns or seek social support or psychological support [57]. This results in many young males remaining or becoming disconnected from supportive and caring adults who are willing to listen to their concerns and offer support.
Frameworks for Engaging AYA Males
Trauma-Informed Care Framework
An AYA male-centered space creates an environment that is safe, welcoming, and inclusive. Adolescents, in general, and sometimes young adults, can evoke strong emotional responses and can make them vulnerable to our unconscious biases [58]. Similarly, many AYA males, particularly in groups, but sometimes as individuals, can evoke strong emotional responses, sometimes based on systemic factors such as unconscious racism or homophobia. The confines of the ideals of masculinity can create trauma, particularly as it relates to mental health [59–61]. The toxic effects of these and sometimes more obvious physically and emotionally traumatic experiences, such as overall aspects of poverty, arrests, and incarcerations can create a sense of powerlessness that in turn generates feelings of resentment and anger [60]. It is imperative that clinical environments, at a minimum, do not recreate these experiences.
A trauma-informed care framework can be one component in addressing these issues [59]. Trauma-informed care stresses the importance of providers and staff being sensitive, receptive, and understanding of the complex issues that AYA males face. This understanding must encompass the issues of masculinity, racism, discrimination, and poverty and the role these issues play on the physical and mental health of these young males. The presence of these issues also serves as barriers to healthcare access [59].
Providers must therefore develop an understanding of the issues faced by young males, recognize the symptoms of these issues, and respond in an appropriate manner. The most significant protective factor for adolescents and especially those who have experienced trauma is a healthy relationship with at least one caring adult [59, 60]. Developing and maintaining a supportive and trusting relationship with a young man may directly benefit their health. In this way healthcare providers are in a unique position to offer the support and healthy relationship that many AYA males need.
Positive Youth Development and Strength-Based Frameworks
The foundation of a Positive Youth Development (PYD) framework is assessing and building on the strengths of AYA male patients, rather than focusing on problems [62]. The PYD framework includes three basic assumptions:
1.
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Focus on strengths and assets rather than deficits and problems.
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Hypogonadism: The Relationship to Cardiometabolic Syndrome and the Controversy Behind Testosterone Replacement Therapy
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