Adolescent/Young Adult Male Services in the Family Planning Setting

1. Adolescent/Young Adult Male Services in the Family Planning Setting Ken Cheyne, MD Adolescent Medicine Blank Children’s Hospital

2. Conflict of Interest • I have no relevant financial relationships with the manufacturer(s) of any commercial products or services discussed in this continuing education activity. • I do not intend to discuss unapproved/investigative use of commercial product(s)/device(s) in my presentation.

3. Objectives • At the conclusion of this training, participants will be able to: • Identify the scope of services recommended in providing care to male clients in the family planning setting. • Conduct a history and physical exam on a male client in the family planning setting. • Identify and provide treatment/referral for common abnormalities of the male reproductive tract. • Provide anticipatory guidance and health related counseling to male clients.

4. References Update: Providing Quality Family Service Planning Services, MMWR, March 11, 2016

5. Male Attendance at Title X Family Planning Clinics • Percentage of family planning users who were male: • 2003 -4.5% • 2014 – 8.8% • Age of users: • 15-19 y/o – 14.4% • 20-29 y/o – 49% • 30-39 y/o – 20.4% MMWR, June 17, 2016

6. MMWRVol. 60: June 6, 2011 Sexual Identity, Sex of Sexual Contacts, and Health-Risk Behaviors Among Students in Grades 9 to 12 – Youth Risk Behavior Surveillance, Selected Sites, United States, 2001-2009

7. Sex of sexual contacts:by sexual identity

8. Sexual Orientation & Risk of PG • Sexually experienced NYC HS students, n=4,892 F & n=4,811 M • YRBS 2005, 2007, and 2009 • Sexual-minority students who were SA were about 2x as likely as other students to report becoming PG or getting someone PG (Lindley & Walsemann. American J Public Health, 2015)

10. Recommended Services for Men • History • Physical exam • Laboratory tests • Sexual & Reproductive health counseling

11. Recommended Services for Men:History • Reproductive life plan • Standard medical history • Visit specific history • Sexual Health assessment • Problems with sexual function • Intimate partner & sexual violence • Alcohol & other drug use • Tobacco use • Immunizations • Depression

12. Recommended Services for MenVisit Specific History • Symptoms / concerns? • Sexually active? Questions / problems? • Use of protection / contraception? Consistency? • Previous history of STI? • Dysuria, urgency, frequency, penile discharge? • Rash, pruritus, lesions? • Questions?

13. Vaccine Options(All vaccines are 0.5 mL IM)

14. ACIP Recommendation • Females: 9vHPV, 4vHPV or 2vHPV for routine vaccination of F 11 or 12 y/o (as early as age 9) and F through age 26. • Males: 9vHPV or 4vHPV for routine vaccination of M 11 or 12 y/o (as early as age 9) and M through age 21. • Also for MSM & immunocompromised persons (including those with HIV) through 26.

15. HEADSSS Mnemonic • H – Home, Health • E– Education, Employment, Eating • A – Activities, Affiliations, Aspirations • D – Drugs • S – Sex • S – Suicide, Sleep • S – Shoplifting, Safety

16. Home / Health • Are there males or male-figures in the form of a parent/guardian in his life? • What is expected of him at home? • What are his roles and responsibilities? • Does he have privacy at home? • Does he experience shame / humiliation at home? • What kind of discipline does he experience at home? • Does he know how to care for his hygiene? • Bathe daily? Deodorant? Floss? Shown how to shave?

17. Education / Employment • What kind of abuse does he experience at school? Verbal, physical, emotional? Is he an instigator and/or victim? • What… • Group does he affiliate with in school? • Is his status in the school’s social structure? • How comfortable is he with his reading ability? • Signs of undiagnosed learning disorder? • Number of hours worked per week?

18. Eating • Is he concerned about his weight? • Nutrition and activity practices? • What is his BMI (5th vital sign)? • How many calories does he drink daily? • Does he weight train? What are his goals? • Does he use sports supplements/steroids? • Is he involved in unsafe sports activities? (e.g. severe weight loss practices in wrestling)

19. Activity / Affiliations / Aspirations • Does he have realistic future goals? • Who does he confide in about personal issues? • Does he have any intimate peer &/or adult relationships? Social support? Best friends? • Who are positive role models in his life? • Nurturers, role models, initiators, mentors, elders • What are his initiation experiences into manhood: both positive and negative (sports, stealing, other risky behaviors, gangs) • Safety in the workplace?

20. Drugs • Experience with inhalants, sports supplements, steroids, chewing tobacco, cigars, binge drinking. • Negative consequences of drug use? • Is he self-medicating? • Does he know how to handle negative consequences of drug use? (e.g., a friend who blacks out or is unresponsive)

21. CRAFFT Screening Questions • C – Have you every ridden in a car driven by someone (including yourself) who was “high” or had been using alcohol or drugs? • R – Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? • A – Do you ever use alcohol or drugs while you are by yourself, alone? • F – Do you ever forget things you did while using alcohol or drugs? • F– Do you or your family or friends ever tell you that you should cut down on your drinking or drug use? • T – Have you ever gotten into trouble while you were using alcohol or drugs?

22. CRAFFT Screening Questions • Two or more positive responses indicate a potentially significant problem • Adolescent should undergo a complete substance abuse evaluation

23. Sex • Has he ever… • Had sex unwillingly? • Gotten someone pregnant? • Is he satisfied having sex? • Had problems when having sex/sexual dysfunction? • Come too soon/late, difficulty getting/losing erection • Is he involved in his child’s life? Why not? • Does he know what “No” really means? • Does he hit/accost/verbally abuse his partner(s)?

24. Sex • Does he know… • Masturbation is normal? Review home rules. Has it ever been discussed? • About hormonal/emergency contraception? How to put on a condom? Effectiveness in pregnancy prevention? • Reason why dual contraception is important? • STI’s can be asymptomatic, some curable, others not? • Follow-up with specific issued related to gay, bisexual and questioning males

25. Family Acceptance Project

26. Family Acceptance Project

27. Family Acceptance Project

28. Family Acceptance Project

29. Suicide / Depression • What are his intrinsic qualities? • Disengaged, shy, anxious, extroverted? • How does he… • Express himself? What skills does he need to interact? • Deal with stress, anxiety? • Deal with gender role strain-shame, humiliation?

30. Suicide / Depression • Does he have signs of depression (non-typical)? • Irritable, anxious, “moody”, angry, rage, sarcastic, rebellious, boredom, social withdrawal • Is he at a crucial juncture and how is he coping? • Detention, school drop out, homeless, etc.

31. Screening Tool for Depression • Have you felt little interest or pleasure in doing things over the past 2 weeks? • Have you felt down, depressed, or hopeless over the past 2 weeks? • 0=never • 1=several days • 2=more than half the days • 3=nearly every day • Score: 0-2—no further assessment, 3-6—complete PHQ-9

32. Screening Tool for Depression Ages 12 to 18 <5 minutes to complete & < 1 minute to score Score ≥ 11 is positive If answer to either question 12 or 13 is Yes – positive

33. Safety • What do you do when you are in an unsafe situation? Give an example. • Ever been jumped and/or assaulted anyone? • Ever been arrested? For what?

34. Safety • Assess for injury risk and co-occurrence of risk behaviors: • Drink & drive (self, peers), drink & swim? • Seat belt, helmet use – driving, biking, skating, etc. ? • Have sex while intoxicated? • Gotten into physical fights? • Carry weapons? Gun in house?

35. Circle of Courage: Looking for Strengths

36. Recommended Services for Men:PE • Height • Weight • BMI • BP • External genital / perianal exam

37. Genital Exam of the Adolescent / Young Adult Male • Inspection • Tanner stage • Circumcised or uncircumcised • L testicle lower than R in the scrotum • Rashes, vesicles, lesions?

38. Circumcised Uncircumcised

39. Inspection of the urethral meatus

40. Inspection of the scrotum

41. Genital Exam of the Adolescent / Young Adult Male • Palpation • Inguinal nodes • Testicles for tenderness / masses • Epididymis for tenderness

43. Perianal Exam • Inspection of perirectal area • Lesions / vesicles • Hemorrhoids • Fissures

44. Perianal Exam Findings Hemorrhoid Rectal fissure Condyloma lata Condyloma acuminata

45. Recommended Services for Men:Laboratory Tests • Chlamydia • Gonorrhea • Syphilis • HIV/AIDS • Hepatitis C • Diabetes

46. Screening: Adolescent Men • Consider screening all SA ≤ 25 y/o in clinical settings associated with high prevalence of chlamydia • HIV screening encouraged

47. Screening: Adolescent MSM • At least annually: • HIV serology, if neg or not tested within previous year • Syphilis serology • Urethral screening for N. gonorrhoea and C. Trachomatis if insertive intercourse during the preceding year (NATT on urine is preferred)

48. Screening: Adolescent MSM • At least annually: • Rectal screening for N. gonorrhoeae & C. trachomatis if receptive anal intercourse during preceding year • Pharyngeal screening for N. gonorrhoeae if receptive oral intercourse during preceding year. CDC does not recommend testing for C. trachomatis pharyngeal infection. • Evaluation for HSV-2 infection with type-specific serology can be considered if infection status is unknown

49. Screening Algorithms in Asymptomatic MSM: Chlamydia and GC 8.6% 86.7% San Francisco City Clinic, 2008-2009

50. F/U of Chlamydia & Gonorrhea • All sex partners within the past 60 days should be (evaluated) and treated • Follow-up: • Tests of cure are not routinely recommended • Both men and women should be re-tested in 3 months