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Trainees, enter the Adolescent and Young Adult Male Health: A Review
Abstract
Adolescent and young adult male health receives little attention, despite the potential for positive effects on adult quality and length of life and reduction of health disparities and social inequalities. Pediatric providers, as the medical home for adolescents, are well positioned to address young men’s health needs. This review has 2 primary objectives. The first is to review the literature on young men’s health, focusing on morbidity and mortality in key areas of health and well-being. The second is to provide a clinically relevant review of the best practices in young men’s health. This review covers male health issues related to health care access and the Centers for Disease Control and Prevention’s Healthy 2020 objectives for adolescents and young adults, focusing on the objectives for chronic illness, mortality, unintentional injury and violence, mental health and substance use, and reproductive and sexual health. We focus, in particular, on gender-specific issues, particularly in reproductive and sexual health. The review provides recommendations for the overall care of adolescent and young adult males.
- AAP —
- American Academy of Pediatrics
- CDC —
- Centers for Disease Control and Prevention
- MSM —
- men who have sex with men
- STI —
- sexually transmitted infections
This is the first article in our series on Adolescent Health.
Introduction
Adolescence is a key time period during which risk and protective behaviors are initiated that will influence overall health in adulthood. Failure to adequately address adolescent health can jeopardize earlier investments in child health and lead to deleterious effects on adult health, health disparities, and social inequality.1 Adolescent and young adult males are a group of particular concern. Compared with females, adolescent males have higher mortality, less engagement in primary care, and high levels of unmet health care needs.2 This review has 2 primary objectives. The first is to review the literature on young men’s health, focusing on morbidity and mortality in key areas of health and well-being. The second is to provide a clinically relevant review of the best practices in young men’s health.
Review Structure
This review begins with health care access, then describes young men’s health in terms of the selected Centers for Disease Control and Prevention’s (CDC) Healthy 2020 objectives relevant to adolescents and young adults in a clinical setting (Table 1). These objectives address chronic illness, mortality, unintentional injury, violence, mental health and substance use, and sexual and reproductive health.3 The discussion of the current state of adolescent male health is followed by a brief set of recommendations and references that position the reader to learn more about best practices for adolescent care. For male sexuality and reproductive health, there are marked gender differences and less emphasis on training programs. Therefore, a more detailed review of best practices is provided.
Selected Healthy 2020 Objectives
Methodology
Using selected CDC health objectives, this review relies primarily on peer-reviewed articles and evidence-based guidelines, such as the United States Preventative Services Task Force and the American Academy of Pediatrics (AAP) practice guidelines for key information and recommendations. We recognize that, in some areas, best practices consist of expert opinion. We also note that adolescent male health must be understood in the context of the adolescent’s social and physical environment.1 For adolescent males, 2 key influences are development and gender. These guidelines are supplemented by social science research on development, focusing on the transitions inherent in adolescence, and on gender, focusing on the role of masculinity in health access and health status across the CDC’s critical health objectives.
Development
For this review, we consider both the adolescent and “emerging” or young adult population. Adolescents can be defined by age, development, and social roles.4 The AAP defines adolescence as up to 21 years of age.5 However, there is increasing attention to 20- to 24-year-olds as “emerging adults” in American society whose developmental challenges, transitional roles, and threats to health and well-being are similar to those of adolescents.6 Supporting the incorporation of the young adult population, the National Initiative to Improve Adolescent Health identifies 10 to 24 years of age as their target population.7 Over 64 million 10- to 24-year-olds live in the United States, representing roughly 21% of the population.8 Males comprise half of this population.
Masculinity
Masculinity can be defined as a set of shared social beliefs about how men should present themselves. Masculinity includes the beliefs that young men should be self-reliant, physically tough, not show emotion, dominant and sure of themselves, and ready for sex.9,10 Homophobia can be an important part of enacting masculinity.9,10 Among adults, masculine beliefs are associated with poor health outcomes across a variety of areas, from cardiovascular disease to care seeking.11,12 Among adolescents and young adult males, masculine beliefs have not only been associated with poor sexual health outcomes, but also poorer mental health outcomes and lower levels of engagement with health services.13–16 Thus masculinity has implications for both engaging young men in health care and for maximizing their health status.
Health Care Access
Gender and age disparities exist in access to health care, with adolescent and young adult males with particularly limited access to care. Less than half of 12- to 17-year-olds (both males and females) receive the recommended yearly preventive care visit.17 (See Table 2 for a summary of recommended preventive visits.) Compared with females, young adult males are less likely to have a usual source of health care (63% vs 78%), are less likely to have visited a doctor in the past 12 months (59% vs 81%), and are less likely to have had an emergency department visit in the past 12 months (19% vs 27%).18,19 Access is closely related to ability to pay for health care. Although expansions in Medicaid and the State Children’s Health Insurance Plans have increased coverage for adolescents 18 years and younger, young adults have the lowest rates of health insurance among all age groups, and young adult males have lower rates than young adult females.18–20 Between 2005 and 2011, only 63% of 18- to 25-year-old males had any type of insurance coverage.20 The expansion of dependent coverage under the Affordable Care Act, starting in 2011, has led to gains (as high as 8% between 2011 and 2013) for young adult males.20 Even with the expansion, young adult males continue to have unacceptably low coverage rates. Care-seeking and access also vary as a function of adherence to conventional masculine values, with less care-seeking and lower access among young men with stronger masculine values.14,15
Chronic Illness
Adolescence is an important time for prevention and early recognition of adult chronic illnesses. The CDC identifies reduced tobacco use, reduced rates of obesity, and increased physical activity as 3 primary goals in chronic disease prevention. Marked gender, age, and ethnic disparities exist. For tobacco use, the prevalence of having ever smoked cigarettes was higher among male than female high school students (46% vs 43%), higher among older students than younger students, and higher among white students compared with African Americans and Latinos.21 Compared with females, male students were also more likely to have started smoking before 13 years of age (12% vs 8%), to be a daily smoker (11% vs 9%), and to smoke more than 10 cigarettes a day (9% vs 6%).21
Gender-related disparities exist in cardiovascular risk factors. In contrast to adults, adolescent males have a higher prevalence of obesity than females (20% for male 12- to 19-year-olds, compared with 17% for females), and, whereas rates of obesity have not significantly changed for females, rates of obesity for males have increased from 1999–2000 to 2009–2010.22 Among obese adolescents, over half had insulin resistance.23 A smaller regional study found that 4% of obese adolescents had type II diabetes mellitus with marked racial and ethnic variation.24 In a nationally representative sample, 12% of all 18- to 24-year-olds had a systolic blood pressure >140 mm Hg, with male gender and obesity being 2 key predictors.25
Prevention data are more promising. Physical activity is higher in males compared with females, with 38.3% of high school males reporting 60 minutes of daily exercise, compared with 18.5% of females.26
Guidelines exist for screening adolescents for blood pressure, BMI, diabetes, and lipids. These are compared and summarized in Table 2.
Mortality, Injury, and Violence
Mortality increases rapidly across adolescence. Although males have seen marked improvements over the past 20 years, their mortality remains unacceptably high, with the United States having the sixth highest adolescent male mortality among high-income countries.27 Compared with females, males in high-income countries such as the United States are more likely to die of all major causes of mortality, including unintentional injuries, suicide, and homicide.28 Unintentional injury alone, which includes motor vehicle injuries, unintentional poisoning, drowning, and unintentional discharge of a firearm, account for 75% of all mortality.27 Marked gender differences also exist in violence-related mortality, with adolescent and young adult males over twice as likely to die of violence as females.29
Morbidity from intentional/violence-related and unintentional injury (without mortality) is similarly more common in males. Adolescents were 11 times more likely to be treated for intentional injury/violence in emergency departments than younger children, and males were more likely to be treated than females.30 Behaviors leading to violence and injury, such as fighting and weapon carrying, are more common in males, with over 25% of high school males reporting weapon carrying in the past 30 days and 9% gun carrying, a four- to sixfold increase over females.21 Important causes of intentional injury among adolescents are drunk driving and texting while driving. Among high school students, boys were less likely than girls to ride with a driver who had been drinking (23% vs 25%), but more likely to drive themselves after drinking (10% vs 7%) and text while driving (35% vs 30%).21
Witness to violence has negative health effects, including post-traumatic stress disorder, depression and anxiety, distress, aggression, and externalizing behaviors.31 In a national survey, approximately half of all 13- to 17-year-olds witnessed violence in the previous year, with nearly 10% witnessing family assault, 42% witnessing an assault in their community, 1.3% witnessing murder, 10% witnessing a shooting, and 2% witnessing war.32 Exposure is significantly more common in males, urban youth, ethnic minorities, and lower income youth. Across studies of urban, low-income youth, ∼25% have witnessed murder.31
Relationship and Gender-Related Violence
Relationship and gender-related violence is a problem for both genders. Although males are often thought of as perpetrators, they are also frequently victims. In 2011, 4.5% of high school males reported forced intercourse (compared with 11.8% of females); in other forms of dating violence, rates are similar between males and females, with 9.5% of high school males and 9.3% of females reporting that their partner hit, slapped, or physically hurt them.21
Compared with their heterosexual youth, sexual minority males (gay, transgendered youth) report higher rates of verbal, physical, and sexual harassment and violence. Most sexual minority and gender nonconforming males have heard homophobic comments at school and/or felt unsafe at school; many report being threatened with a weapon or attacked at school.33,34 Together these findings support screening adolescent males, particularly gender nonconforming and sexual minority males, for relationship and gender-related violence.
Mental Health and Substance Use
Depression and Suicide
Depressive symptoms and depression are common in adolescent males, with 19% of high school males reporting feeling sad or hopeless,21 and 4.6% of 13- to 18-year-old boys having depression.35 Males are more likely to die of suicide than females, and sexual minority males have increased risk for suicidal attempts and ideation compared with heterosexual males.36 This is believed to be attributable to stigma and lack of social support.36
Substance Abuse
Alcohol and drug use are also more common among males. Among high school males, 39.5% report any alcohol use in the past 30 days, and 23.8% report consuming >5 drinks.21 Drug use is common, with 25.9% reporting marijuana use in the past 30 days, 10.5% inhalant use, 9.8% ecstasy use, and 21.5% prescription drug use (such as oxycodone, hydrocodone, benzodiazepines, etc).21 Early use (before age 13 years) is common (23.3% of males reporting early alcohol use and 10.4% early marijuana use), with risk factors including low supervision and parental monitoring.21,37 Higher rates of substance use have been reported among sexual minority youth.34
Overview of Sexual and Reproductive Health
Genital Exams
Only 37% of males 15 to 44 years old had a testicular examination in the past year.38 Although current guidelines do not support clinician examination or teaching males self-testicular examinations for the purposes of testicular cancer screening, testicular examinations are an important part of assessment of normal growth and development, and the Society for Adolescent Health and Medicine recommends that male genital examinations be a part of adolescent primary care.39,40 To that end, a clinician must be familiar with normal male genital development, be able to reassure patients and parents about normal physical examination findings, and recognize, treat, and, if appropriate, refer abnormal findings. Normalization is an important part of adolescent primary care, given the wide variation in onset of puberty and adolescent males’ concerns, and frequently unrealistic beliefs, about normal penis size and shape. A European cohort study described the median onset of puberty as 11 years of age with significant variation of genital growth and development.41 For example, 14-year-olds had a mean penile length of 8 cm, with a range of 5.6 cm to 10 cm, and a mean testicular volume of 10 mL, with a range from 5 mL to 20 mL.41 There is no predictable relationship between size of flaccid and erect penis length.42
Other common normal pubertal concerns include wet dreams, erections, pubertal gynecomastia, pearly penile papules, and sebaceous cysts. Common abnormal male genital concerns include phimosis and paraphimosis, scrotal masses including hernias, hydroceles, varicoceles, spermatoceles, orchitis, and testicular neoplasms, and causes of testicular pain including torsion, torsion of a testicular or epididymal appendage, and epididymitis. Table 3 describes these findings and describes initial primary care management.
Normal and Abnormal Reproductive and Sexual Health Concerns in Adolescent Males (108–117)
Circumcision is an area of relative controversy. Evidence from countries with high HIV prevalence suggests circumcision is protective against acquiring HIV and other sexually transmitted infections (STIs).43,44 It is controversial whether the same benefits exist in low prevalence countries. Recently the AAP has recommended that the benefits outweigh the risks of newborn circumcision45; circumcision later in childhood in the United States has not been addressed.
Sexual Health
Sexual health incorporates sexual behavior disease prevention, healthy relationships, and sexuality, and includes skills such as the capacity to appreciate one’s body, express love and intimacy in appropriate ways, and to enjoy and express one’s sexuality.46
Many adolescent males choose to delay sex, with only 28% of 15- to 17-year-olds and 64% of 18- to 19-year-olds reporting ever having intercourse.47 Particularly for younger adolescents, sex is often infrequent and sporadic. Only 12.1% of 15- to 17-year-olds and 36.5% of 18- to 19-year-olds report having had sex in the past month.47 Among high-risk males, such as juvenile justice or STI clinic attendees, the proportion who are sexually experienced is much higher.48–50 Although not all sexual behavior is problematic, a young age of onset is associated with increased rates of sexual coercion, STIs, and early fatherhood.51
Adolescent and young adult males 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, 1.7% with Trichomonas, and 0.4% with gonorrhea.52,53 Early fatherhood is common, with 15% fathering a child before age 20 years.47
These sexual health morbidities are related not just to sexual practices, but to partners, pregnancy, and STI prevention behavior. Among all 15- to 19-year-old males, 85.4% reported any method of contraception, including 79.6% condom use and 16.2% dual contraceptive use with a hormonal method and condoms.47 Although a small minority (4.5%) of sexually experienced adolescent males report 4 or more partners, the majority of 15- to 17-year-olds (56.5%) and a sizeable minority of 18- to 19-year-old males (37.1%) have had only 1 to 2 lifetime female partners.47
Relationships
Adolescent males’ early sexual experiences are generally situated within romantic relationships. Among 15- to 19-year-olds, 58% reported first sex with a steady romantic partner, and 12% with someone they were going out with once in a while.47 Particularly for younger adolescent males, curiosity, uncertainty, lower levels of relationship power (ie, who makes decisions and determines relationship activities), and a desire for friendship, intimacy, and closeness characterize these early relationships.54–56 Among very young adolescents, both males and females described a high degree of curiosity about sex,57 and concerns about “readiness” for sex.57,58 Among 14-year-olds, males reported high uncertainty and lower power in relationships, and multiple studies describe adolescent males’ desires for love and emotional attachment.54,55,58 Although males were more likely than females to describe first intercourse as “wanted,” approximately one third reported mixed feelings, and 5% of males reported first intercourse as unwanted.47 Most adolescent males would not prefer to make a partner pregnant; only 15% of 15- to 19-year-olds would have been pleased if they caused a pregnancy.47
Sexual Minority and Young Men Who Have Sex With Men
An important aspect of adolescent males’ sexuality is the development and expression of sexual orientation and sexual identity. Sexual orientation is a multidimensional concept referring to an enduring pattern of emotional, romantic, and/or sexual attractions to females, males, or both sexes.34 Sexual identity is an individual’s conception of his own sexuality and may not always be congruent with his sexual orientation or sexual behavior.34 Current best estimates of sexual orientation in youth are 3% of males identify as homosexual or bisexual and 2% report same-sex sexual attractions.59 Although sexual orientation is often categorized as gay, straight, bisexual, or questioning, orientation and sexual identity operate along a continuum.
Although sexual health risk is linked to sexual behavior with same-gender partners, same-gender sexual behavior is not the same as sexual orientation. It may indicate sexual orientation; it may also represent experimentation and/or exploration. Among 15- to 17-year-olds, 1.7% reported same-gender sexual behavior, among 18- to 19-year-olds, that percentage increases to 3.8%, and among 20- to 24-year-olds, 5.6%.59 Compared with men who have sex with women, rates of HIV and STIs are higher among young men who have sex with men (MSM).60,61 Young MSM of color have the highest rates of HIV and STIs.62 MSM account for the largest numbers of new HIV infections. In 2009 young MSM accounted for 69% of new HIV infections and 44% among all MSM. From 2006 to 2009, HIV infections among young black/African American gay and bisexual men increased 48%.63 In 2006, 64% of the reported primary and secondary syphilis cases were among MSM.64 Gay and bisexual identified young men report higher levels of risk behaviors, including delinquency, aggression, and substance use. These differences, however, are moderated by individual, relationship, and environmental factors, such as attitudes toward risk-taking, peer victimization, parental relationships, and substance availability.65
Stigma arises from environments and individuals who are dismissive, openly rejecting, and occasionally hostile toward sexual orientation. Stigma is a particularly important moderating factor in the disparities in physical, mental, and sexual health outcomes observed in sexual minority youth.34,66,67 These health disparities range from increased rates of depression, suicide, and disordered eating to substance abuse, HIV, and STI acquisition. Supportive family, friend, and school networks can mediate these associations, for example, decreasing suicide risk.34,68
Recommendations
Pediatric health providers can be important resources for sexual health for adolescent males. Below are recommendations on an approach to adolescent and young adult males, grounded in data and best practices. These recommendations are fundamentally based on positive youth development models and a “strength-based” approach.
Positive youth development is a growing field promoting the healthy development and positive outcomes of young people versus focusing solely on traditional problem-focused views of youth.69 Clinical care often focuses on risk behaviors, which often define young males.70 A positive youth development approach changes the focus to acknowledge and promote their strengths.71,72 In a psychosocial history, the positive youth development model suggests that clinicians begin with questions that identify strengths and assets.69,73 This contributes to a relationship that nurtures, empathizes, and builds a more positive self for the young man, which influences behavior changes and decreases risk.70 As part of a strength-based approach, clinicians can acknowledge gender role stereotypes and the conflicting role expectations that males are taught.70 This can result in an opportunity for the young man to share any concerns in a confidential setting.
Engage male youth in care. Assess and build upon strengths.
Provide time and a safe space for confidential conversations about sensitive topics.
Approach sensitive topics in respectful 2-way conversations, rather than in a lecture style. Motivational-interviewing–based approaches are recommended for engaging with all adolescents, despite the focus of its use with specific risk behaviors.
Involve parents; they can support healthy adolescent development.
Screen for tobacco use.
Recommend smoking cessation.
Screen for obesity, using BMI-for-age.
Screen for diabetes for adolescent males who are overweight and have 2 risk factors.
Screen for hyperlipidemia.
Recommend healthy lifestyles.
Mortality, Violence, and Unintentional Injuries80–82
Screen for weapon ownership.
Screen for interpersonal violence and domestic violence.
Screen for suicide.
Discuss driving safety with parents and teens: seat belt use, risks of having passengers in the car, and night driving.
Know whether your state has a Graduated Licensing Program.
Mental Health and Substance Use83,84
Screen for depression and suicide.
With positive screen, treat and/or refer for treatment.
Screen for alcohol use and binge drinking.
Screen for substance use, particularly marijuana and steroid use.
Sexual and Reproductive Health85
Screen for sexual activity.
Promote abstinence for adolescents age 17 years and younger.
Assess personal assumptions about boys and masculinity, particularly around care-seeking and relationships.
Engage adolescents in conversations about healthy relationships and safer sexual behaviors, beyond simple messages about abstinence and condom use.
Encourage the adolescent to adopt a definition of masculinity that allows and promotes health and respectful relationships and genuine communication. Use gender-neutral language and do not assume heterosexuality.
However, ask about gender of sexual partners and the gender of those whom they are sexually attracted to.
Discuss and appropriately screen for STIs.
Screen based on the adolescent’s sexual behavior according to CDC guidelines, not according to the adolescent’s sexual orientation or identity.
Include Hepatitis A, Hepatitis B, and human papilloma virus vaccinations as primary prevention efforts for males.
Promote condom use. Advise males to sample and choose the condom that feels and fits best rather than propose that 1 size fits and functions for all.
Educate males about emergency contraception.
Educate and promote dual contraception with males; educate and dispel myths about hormonal methods and long-acting contraceptive methods.
Specific Recommendations for Working With Transgender and Sexual Minority Youth
If one does not feel comfortable providing high-quality care to sexual minorities or transgender youth, one should refer the youth to a health care provider in their community who can.
Be prepared to respond to questions or concerns about disclosing or “coming out” to family and/or friends. Discuss the timing and approach to disclosure as well as the potential repercussions. Be a support for both the parents and the adolescent.
Evaluate or refer for evaluation gender nonconforming youth, inclusive of the possibility of transitioning to the desired gender.
Footnotes
- Accepted June 20, 2013.
- Address correspondence to David L. Bell, MD, MPH, Medical Director, The Young Men’s Clinic, Center for Community Health & Education, 60 Haven, B3, New York, NY 10032. E-mail: dlb54{at}columbia.edu
Dr Bell conceptualized the manuscript, drafted the initial manuscript, reviewed and revised the manuscript, critically reviewed and approved the final manuscript as submitted; Dr Breland conceptualized the manuscript, drafted sections of the manuscript, reviewed and approved the final manuscript as submitted; and Dr Ott conceptualized the manuscript, reviewed and revised the manuscript, critically reviewed and approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on page 571, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2013-1928.
↵* References listed in this section are suggested readings
References
- Copyright © 2013 by the American Academy of Pediatrics
