Making the most of the adolescent male health visit Part 1: History and anticipatory guidance

DR. MARCELL is an assistant professor in the division of adolescent and young adult medicine, department of pediatrics, University of Maryland, Baltimore, Md.  Support for Dr. Marcell’s work was provided by NICHD. (1 K23 HD47457-01)

DR. BELL is assistant clinical professor in the departments of pediatrics and of population and family health, and medical director of the Young Men’s Clinic and the School-Based Clinic Program of the Center for Community Health and Education Institution at Mailman School of Public Health, Columbia University, New York, NY.

Staff editors: JULIA RUSSELL, Managing Editor, MARIAN FREEDMAN, Contributing Editor, and JOHN BARANOWSKI, Editor, Contemporary Pediatrics

The authors, manuscript reviewers, and staff editors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

Making the most of the adolescent male health visit

Part 1: History and anticipatory guidance

BY ARIK V. MARCELL, MD, MPH, AND DAVID L. BELL, MD, MPH

A structured psychosocial interview allows you to assess if, and how, a male teenager’s lifestyle or home and school environment pose a risk to his mental and physical health.  The authors show you the right questions to ask and how to ask them – the keys to getting your patient to open up.

The visit of an adolescent male to your office provides a unique opportunity to make a clinical connection with someone who may otherwise have few interactions with the health-care system.  The adolescent male typically is considered “healthy,” but aspects of his lifestyle may place him at risk of significant morbidity and mortality.  Finding out about these risks may not be as difficult as you think.  Although the adolescent male has a reputation for being nontalkative, difficult to engage, or disinterested in clinical matters, these young men do want to discuss their health, but only in a comfortable environment and in response to sensitive questioning and respect for their need for privacy.  The busy office environment does not make it easy to meet these requirements, especially since it limits time spent with patients.  You therefore need to be aware of the broad scope of the adolescent male visit and know what to ask your adolescent male patient, and how to ask it.

                In this first of two articles on the adolescent male office visit (the second, in the June issue of Contemporary Pediatrics, discusses the physical exam), we offer pointers for using a structured interview to obtain the all-important psychosocial history.  We also offer suggestions for providing developmentally appropriate anticipatory guidance.

Creating a comfortable environment

Assuming that your office environment already is welcoming to adolescents, not just children, review whether the types of posters, brochures, magazines, videos, and other resources you use are of interest to young men.  In many offices, these resources appeal mainly to females.  An easy way to make this evaluation is to ask a male teenager (or a group of teenagers) to review the materials and to make recommendations.  The box on page 56 lists sources for male-friendly materials for your office; you may also want to refer patients who need additional information about a particular topic to one or more of these sources.  Also see “Creating a safe space for confidential conversations” on page 52.

                Encourage family members to remain in the room as you start the visit.  Address your patient directly to make him feel comfortable in his new medical home.  Review with him the clinic hours, the best telephone number(s) to call, after-hours protocols, what to expect during his first visit, and confidentiality issues.  Tell him how often you expect to see him and what services you will provide during future visits.  Recognize that mothers usually make appointments, particularly for younger adolescents.  Encourage him to make the appointments himself, especially as he gets older.

                Taking the medical and psychosocial history while the patient remains clothed increases the young man’s comfort level and makes it less likely he’ll be distracted.  For the same reason, be sure also not to be interrupted.

First things first: Taking the medical history

Having the parent or guardian in the examination room while you take the medical history of the patient and his family enhances accuracy and completeness.  Use a family tree, or genogram, to help map medical illnesses that run in the family.  Identify the patient’s existing medical health issues and classify his risk for future problems, such as obesity and diabetes.  Most often, the adolescent male’s health problems are caused by lifestyle choices and psychosocial factors.  They may also seek medical attention for acute or chronic medical issues including asthma, acne, and hypertension.  Obtain a current list of medications, medication allergies, and vaccinations.

Making the psychosocial assessment

Ask the parent or guardian to step out of the examination room before you begin the more sensitive and confidential psychosocial history (see “Creating a safe space for confidential conversations”).  When taking a psychosocial history, use a balance of closed-ended questions, which can be answered with a few words, often simply “Yes” or “No,” and open-ended questions, which solicit more information.  Practicing “active” listening – showing you are focused on what the patient is saying and offering appropriate physical and verbal responses – also is important.  Giving the patient a standard questionnaire to complete at home before the visit or in the office can be a time-efficient and useful way to ask closed-ended questions, allowing you to spend your limited time asking about the most pressing issues during the initial visit.  You can address less urgent issues at subsequent visits.

                Many strategies have been developed to organize the taking of an adolescent’s psychosocial history.  The HEEADSSS system (which stands for Home, Education/employment, Eating, peer-group Activities, Drugs, Sexuality, Suicide/depression, and Safety), designed for both genders, allows you to rapidly assess a youth’s psychosocial development and behavior, moving from less-sensitive areas, such as home environment, to more sensitive topics, such as suicidal feelings.¹  (See “Getting into adolescent heads: An essential update,” January 2004, available at http://www.contemporarypediatrics.com.)  During initial and follow-up visits, you can tailor questions to match the developmental stage of the individual adolescent.  To aid in this endeavor, we developed a Level 2-HEEADSSS psychosocial interview (Table 1) to tap issues of particular relevance to the adolescent male at various stages of adolescence and young adulthood.  This assessment instrument covers the same general areas as HEEADSSS and can be used in conjunction with that interview.  The following discussion – which covers, in order, each of the areas addressed in the two instruments – is intended to clarify the questions they raise and to trigger additional queries.

Home

Does the young man have positive role models in his life?  Adolescents who have strong connections to their parents or other adults are protected from engaging in problem behaviors.²  Do not assume he lives in a nuclear family; his parents may be divorced or he may live in a single-parent household or be cared for by other guardians or relatives.  He may also be cared for in foster care, a residential home, or a detention facility.  Assess the patient’s connection to his parents or guardians.  Ask him to name the adult to whom he can talk about anything or to rate his relationship with his parents on a scale from 1 to 10.  Ask him what it would take for a parent to rate a 10.

                Other positive role models other than parents who are important to the male’s development include initiators (those who help the male transition from childhood to adulthood), mentors (teachers, coaches), elders (grandparents), and friends or celebrities.  You may want to find out if the adolescent has positive interactions with persons from each of these categories.  Role models can be male or female.  But don’t forget that, because the home and school environments of many male adolescents are dominated by women, a young man may have no father or other significant male figure in his life.  Help the patient deal with any anger he may feel at the absence of a father, and refer him and his family to organizations in the community, or to other family friends and relatives that can serve as positive role models.

                Determine the type and extent of support and discipline the patient experiences in his home.  What is his role in the household and what responsibilities does he have?  Does he ever feel ashamed or humiliated?  Do family members bully or tease him?  Assess why your patient is being teased and who is doing it, and help the parent develop appropriate support and discipline for experiences in the home.

                Family discord can arise from a variety of situations, including parenting style, lack of privacy, or role expectations.  Review parenting style with parents.  Children and adolescents raised by parents who are authoritative tend to do better than those raised by parents who are authoritarian or permissive.³  Assess how much privacy your patient has.  It is normal for the young adolescent male, whose body is changing rapidly, to insist on independence and privacy when bathing and in other personal activities.  The young man in mid adolescence may want to spend more time alone in his room or private time on the phone than he did when he was younger; disengagement with the family and family activities is also common during this time.  Families who consider this behavior a sign of being “lazy” or “nonengaged” may need help in creating realistic expectations about the young man’s roles and responsibilities.  Consulting with a social worker and psychologist, if available, often in helpful in these situations.

                A pediatrician may earn instant credibility in the eyes of an adolescent male by offering simple advice about hygiene.  Start these discussions in early adolescence, incorporating the advice with other information you provide at that development stage.  You might say, for example, “I talk with all of my adolescent male patients about changes that happen during puberty.  These changes mean that males have to be particularly careful about their hygiene.  Bathing or showering and using deodorant every day in addition to brushing your teeth twice daily and flossing are important.”  Many young men don’t know much about shaving, especially why they should not shave “against the grain.”  You might ask the patient if he has any questions about shaving, which is one example of the male’s initiation into adulthood that typically goes unrecognized.  Consider creating or using one or more handouts to address safe and recommended hygiene practices and products.

Education

School is where the adolescent male spends most of his time outside his home and where he interacts with peers.  Learn about the schools in your area so that you become more aware about the school environments your patients are experiencing.  Your patient can also serve as an informant and tell you about his school’s peer groups and cliques.  Assume that, at some point in his childhood or adolescence, the male has experienced some form of teasing or bullying in school.^4,5  Males living in boarding schools, military schools, or residential facilities may be subject to even more of these experiences.  Ask about specific experiences as a victim or as an instigator of abuse.  If the patient is a victim, ask him how he copes.  If he has instigated the abuse, ask about his motivation.  Then, develop a plan to curtail this activity.  Each plan should be tailored to the specific circumstance.  Although intervention may be difficult, use of humor to diffuse tense situations, learning how to speak up for oneself, and learning how to leave the situation if possible should be discussed and role played.⁴

                An adolescent male often is brought to the office, especially during early adolescence, for evaluation of a behavioral problem that typically is identified by a teacher or a parent.  The problem may result from classmates’ teasing or bullying, undiagnosed attention deficit hyperactivity disorder, conduct disorder, depression or another mental health problem, substance abuse, delinquency, or an undiagnosed learning disability.  Learning disorders may go unrecognized, especially during times of transition, such as the move from elementary school to junior high school.  A suspected undiagnosed learning disorder merits further evaluation by the child’s school for an individualized education plan.  Or, refer the young man to a behavioral or educational psychologist for evaluation.

                Encourage the young man, especially during middle and late adolescence, to think about future professional plans.  He needs to be practical; some adolescents have appropriate aspirations, whereas others may be less practical such as planning to become a starting linebacker for a professional sports team or the next pop star.  Some adolescents are college-bound; for others, stress the importance of a baseline education and that earning a high school diploma or a high school equivalency certificate (GED) is basic to most career paths.  The adolescent who has no future goals should be evaluated for depression and substance abuse.  Recognize, however, that some adolescent males do not wish to pursue an academic path and should be referred for vocational schooling, vocational counseling, or Job Corps, a residential educational and job training program run by the US Department of Labor.

Eating and exercise

Having the patient complete a questionnaire is a useful way to assess nutritional issues fairly quickly.  (Useful material can be found at Body basics: An adolescent provider toolkit [http://www.ahwg.net/resources/toolkit.html]).  You then can provide more specific advice about nutrition and physical activity.  If you are not comfortable dispensing this kind of advice, consider referring the patient to a nutritionist.

                Determine whether the adolescent is concerned about his weight or wants to change how his body looks.  Compare your assessment of his weight status, by calculating his body mass index (BMI), with his perception of his body.  Some young men who are obese by BMI standards do not think of themselves as fat.  The reverse is also true; one of every 10 patients diagnosed with anorexia nervosa is male.  Anticipatory guidance in nutrition and physical activity is all that the patient with a normal BMI requires.  The patient with a BMI above the 95^th percentile (defined as overweight by the Centers for Disease Control and Prevention) or between the 85^th and 95^th percentile (at risk of overweight) with positive risk factors requires an in-depth medical assessment.^6-8  A male at or below the 5^th percentile for BMI also requires an in-depth medical assessment and disordered eating must be ruled out.  Remember that BMI is a screening tool.  It may not be as accurate for the male as for the female, especially the male athlete.  Other measurements based on body fat mass, such as triceps skinfold measurements, may be more appropriate.

                Suggest to the overweight patient that he decrease or eliminate high-calorie beverages, such as soda and juice.  An adolescent can easily make this change, which often has positive short- and long-term results.  For athletes, the fluid of choice is water.  Drinking carbohydrate-electrolyte beverages instead of plain water has no benefit.  Also review daily calcium recommendations: 1,300 mg via milk or yogurt at least three times daily or with alternative calcium sources.

                How physically active is the patient?  Adolescents should participate in at least 60 minutes of moderate-intensity physical activity most days of the week, preferably daily.⁹  Does the peripubertal male who is weight training want to become more toned or muscle defined or is he trying to bulk up?  Does he have an unhealthy desire to bulk up that suggests body dysmorphia?  Recommend that his weight training sessions be supervised, and explain that it is safest to use low weights and perform frequent repetitions to tone or define muscle, but that bulking up prior to completion of puberty is unsafe; the peripubertal male should avoid power lifting or bodybuilding until he achieves his maximum height in order to prevent ligament or growth plate injury.

                Inquire if your patient engages in undesirable activities to modify weight or performance, such as using sports supplements, steroids, or laxatives, or by fasting, binging, purging, or sweating.  If he does pursue any of these activities, review his reasons and potential dangers and consequences:

• Is his motivation to enhance his appearance or performance?  Is he being pressured to engage in the activity or is he emulating others?

• The Food and Drug Administration does not regulate many of these products.  As a result, they are potentially unsafe and are not guaranteed (they may contain other harmful chemicals or drugs or the dose may be stronger or weaker than labeled).

• The activity may have short- or long-term negative (or positive) effects, as shown by scientific data.¹⁰

• Engaging in a performance-enhancing activity may have ethical consequences.

• The activity may cost more than the young man can afford.

• Getting caught, especially for using substances that are illegal or banned, poses real risks and consequences.

Brainstorm with the young man about other safe and effective ways to achieve the same goals without being exposed to potentially negative consequences.

Activities

To get a complete picture of your patient’s psychosocial development, explore how he spends his time outside of school.

                “Screen” time.  Adolescent males are particularly high consumers of media (“screen media” includes television, video games, computer entertainment, and movies; other types of media exposure include music devices, radio and print media).  Male children and adolescents are exposed to, on average, eight hours of media a day, including, on average, five hours of “screen” time a day.¹¹  The young adolescent male is particularly vulnerable, as more boys than girls engage in fantasy play during this age period.  The effect of media exposure can have a significantly detrimental effect on male health, increasing the risk of violence, obesity, engaging in sexual behavior, substance abuse, and disordered eating.¹²  Recommend that the patient and his family limit screen time to no more than one or two hours a day, remove television and Internet connections from bedrooms, and do their viewing as a family, discussing what they have seen.  Teach your male patients how to become media literate (able to analyze how the techniques and content of media effect him).  Media literacy can be a powerful way to change behavior because young people hate to feel manipulated.

                Friends and intimates.  Adolescent males tend to have more peer acquaintances than their female counterparts, but these relationships may lack depth and quality.  Ask the patient in whom he confides about personal matters.  Assess whether he has any intimate relationships with a peer or a best friend.  If not, encourage him to develop such relationships.

                Male initiation.  Assess what manhood-initiation experiences the young man has had.  Not only do males lack a biologic marker to signify the onset of maturity, but many do not get a formal positive initiation into manhood, such as being part of a religious ceremony, participating in a sport, or getting a job.  Some young men instead experience harmful initiation rites, such as being coaxed to steal, tease, or bully, joining a gang, or using drugs.  Initiation rites, especially the undesirable ones, should not substitute for more positive and formal training offered by appropriate role models, such as a parent, about what it means to be a responsible adult male.  You can also serve as a role model, initiator, or mentor.  You also can help provide him with positive initiation experiences by developing resources for locating jobs, sports programs, and internships.

                Job safety.  At least one third of adolescents work during the academic year, and many more work during summer.  Male adolescents are more likely than females to work in jobs that place them at risk of injury.  Depending on where the patient works and what he does there, review how he can protect his health and safety on the job.

Drugs

                According to national statistics, adolescent males are more likely than their female counterparts to abuse drugs, including inhalants, cigarettes, smokeless tobacco, cigars, alcohol, marijuana, and heroin.  In questioning the patient about drug use, it helps to know about local patterns – for example, if Ecstasy or other types of street or club drugs are popular where he lives.  Ascertain whether the young man has ever tried drugs and, if so, how often, how much, and the consequences.  Has he driven while intoxicated or been in a vehicle with a driver who was intoxicated?  Has he had sex while intoxicated?  Has he or someone he was with blacked out, gotten sick, or been injured after substance use?  Positive responses to such questions raise red flags about substance use problems.  Screening tools available for clinical use include the CRAFFT assessment, a six-question instrument for adolescents, which is available at www.netwellness.org/healthtopics/substanceabuse/crafft.cfm.  Any patient whom you identify as having a substance use problem requires help, and you should refer him for appropriate treatment.

                Sometimes you can motivate the patient to engage in a conversation about his drug use by commenting on the expense of the substance he uses or the fact that it is illegal.  Review drugs that are legal and those that are not, possession laws in your state, and penalties when you are caught.  Assess how much he pays every week or month for drugs and whether the short- and long-term consequences are worth it.  Suggest to him that there may be more desirable ways for him to spend his money – for example, on his girlfriend.

                Make sure the patient knows how to handle the negative consequences of drug use – especially important when a patient reaches his late teens, because drug use peaks among young adult males, especially among those in college.  In fact, adolescent men who did not use drugs during high school may begin when they get older, so check on the patient’s drug use during his college transition visit or as a young adult.  Does he know how to handle a friend who blacks out or is unresponsive after drinking?  Use role-playing to review what he would do in this situation and teach him how to get appropriate adult help or medical treatment.  In your counseling, also keep in mind that many preventable deaths are caused by binge drinking episodes.

                Also be aware that many people who use drugs do so to cope with mental illness.  Perform a thorough mental health screen with males who abuse drugs.  Also, recognize that adolescent males may not exhibit classic signs of mental illness according to Diagnostic and Statistical Manual, 4^th edition-revised (DSM-IV-R) criteria.¹³

Sexuality

Masturbation and other normal sexual activities, contraception, and sexual and physical abuse are among sexually related topics to explore.

                Puberty and masturbation.  As a young man progresses through pubertal development, it is normal for him to explore his body and compare himself to others.  Typically, he will not remember when the first signs of puberty appeared.  He is unlikely to talk about certain other events, such as the first orgasm (which may be dry) or “wet dream,” or masturbation in general.  Indeed, some families have strict rules against touching oneself or masturbating.  Assure the young man, especially the early adolescent, that these sexual happenings are normal and he should not feel ashamed about them.  Also review any rules at home and whether an adult has ever discussed pubertal changes and sexual activities.  Be sure to ask the patient if he has any questions.  You also may want to refer him to one or more of the Web resources listed in the Guide for Patients at the end of this article for information specifically for teenagers on sex and other subjects.

                Contraception. All adolescent males, whether or not they are sexually active, should learn about methods to protect against unintended pregnancy and sexually transmitted infections (STIs).  Patients need to learn how to put on a condom and know that they are not foolproof (87% effective for typical use, 95% for perfect use).  They also should be knowledgeable about contraception that their partners can use, such as hormonal and emergency methods, and the importance of dual contraception (use of a condom plus a hormonal contraception method).  As part of STI education, tell the patient that some STIs are curable and some are not, and indicate that many STIs can be asymptomatic – two points that are lost on many adolescents.  Provide simple and consistent messages to your patients, such as: “Avoiding sex is the safest way to prevent pregnancy and STIs or HIV/AIDS.”  And, “if you choose to have sex, be responsible and use a condom every time.  If you do not have a condom, do not have sex.”

                Physical and verbal abuse.  Males and females of all ages and races experience sexual abuse.  Even after consensual sex begins, males may report being coerced into sexual activity.  Has the patient ever been touched inappropriately or been forced to have any type of sexual contact, be it oral, anal, penile, or vaginal?  Has he been the victim – or perpetrator – of verbal or physical abuse in a relationship?  If he was in this situation in the past, ask him how he dealt with it and how he feels about it now.  If he is currently a victim, assess why he remains in the relationship and how he responds to his partner’s patterns of abuse.  If he is currently a perpetrator, review what triggers the abusive behaviors and what they are, for example, rage, physical reactions, or “shutting down.”  Does he recognize that these types of behaviors are a problem?  Refer him to anger management services as appropriate.

                Sexual dysfunction.  Male sexual dysfunction during adolescence is common and is usually caused by performance anxiety.¹⁴  If the patient indicates he is having difficulty, let him know that you are pleased he brought up the topic and help him specify the problem.  A useful screening question to initiate a conversation is: “A lot of times young men who are sexually active have questions or concerns about sex – do you have any?”  If he still finds it difficult to go into detail, try giving him some examples: “Some men may be worried because they ejaculate too soon or late or have difficulty getting or losing an erection.  Have you ever experienced any of these problems?”  Offering reassurance and stress reduction techniques are important in this situation, as are obtaining a thorough review of systems and medication history to rule out pathology or medication as the cause.  Agents associated with sexual dysfunction include alcohol, anticonvulsants, antihypertensives (β blockers, not ACE inhibitors), diuretics, H₂-receptor antagonists, nonsteroidal anti-inflammatory drugs, opiates, psychedelics and hallucinogens, tobacco, benzodiazepines, tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, antipsychotics, and lithium.

                Pregnancy and parenthood.  About 2% to 7% of adolescent males are fathers and more than twice that number have been responsible for a pregnancy.  Ask the sexually experienced male if he has ever gotten someone pregnant, is a father, or is going to become a father.  If he responds in the affirmative, ask him about his relationship with his child’s mother and ascertain how involved he is with the child.  If he does not have a relationship with his offspring, find out why.  Whatever his involvement, assess how he is managing the stress of being a teenage parent, and help him connect to resources to provide him with parenting skills.

                Homosexual and bisexual youth.  Avoid making assumptions about whether the male adolescent is heterosexual.  Be sensitive about the specific health needs of males who identify themselves as gay, bisexual, or homosexual, or those who are questioning their sexual orientation.  Excellent resources are available to help you learn how to work with these populations.^15,16  If you are not comfortable with providing this type of service, find an expert in your area who is.

Sadness and suicidality

Using either direct observation or questioning, assess whether the male is disengaged, shy, anxious, or extroverted.  Parents may confirm that a young man has always been shy, or it may be that he is uncomfortable in the office environment or fearful of being examined.  Shyness may also be a red flag for poor self-esteem resulting from teasing or bullying or a delay in puberty – at least in comparison with the patient’s peers.  Encourage parents to help the shy male learn how to socialize with his peers by means of after-school and other socially-engaging activities.  Teach the shy male who is teased by his peers how he can use humor during these situations.  Consultation with a social worker or psychologist, if possible, may help this kind of patient.

                Determine how he deals with stress, anxiety, and threats to his masculinity.  The social environment of boys and adolescent males can be cruel.  Assess the types of stressors your patient faces and how he deals with them.  Ask if he is most likely to express his feelings verbally or through writing or some other creative activity and whether there is anyone in his life in whom he can confide.  Positive role models can help a young man buffer stressful situations.

                Assess whether the adolescent male exhibits nontypical signs of mental illness, especially of depression.  Many males do not demonstrate typical signs of depression or meet DSM-IV-R criteria, which makes recognition difficult.  This is of particular concern because depression is a major risk factor for suicide, the third leading cause of death among adolescent males.  Nontypical signs of depression in the adolescent male include being irritable, anxious, moody, angry, full of rage, sarcastic, rebellious, bored, or socially withdrawn.  Stressors, including the death of a loved one, the breakup of a relationship, or participation in problem behaviors, such as drug use or gang involvement, may also precipitate depression.  Be quick to suspect depression if the patient comes across as completely disengaged during the office visit.  Manage depression in the primary care setting or refer to a mental health professional.

                Certain young men – for example, those who are in detention, have dropped out of school or are at risk of doing so, or who are homeless – require close follow up.  Whether or not such a patient is ready for significant intervention, he may, because of the nature of the office visit, identify you as a significant resource.  Help him feel comfortable in what is, in fact, his medical home.  Assess how well he is coping with his situation, and identify the problems he is facing – they usually are many.  Assist him during this transition period, and help him make short- and long-term plans.  Focus on his health issues and then integrate future planning, such as alternative education or career paths, into your care.  Address specific risk-reduction techniques, too.

Safety

Preventable injury, both unintentional and intentional, is the main cause of death among males.  Relatively few behaviors contribute to most deaths among adolescent males: 1) intoxication, primarily with alcohol, while driving or swimming, and consequent motor vehicle crashes and drowning; 2) lack of appropriate use of safety devices, such as seat belts or helmets when driving a car or riding a motorcycle, bicycle, or skateboard; and 3) access to and use of guns.  Assess whether the patient is at risk in any of these areas, keeping in mind that these behaviors sometimes are combined with other risk behaviors, such as having sex while intoxicated.

                Ask the young man if he feels safe in his community.  Ask him what makes him feel he is not safe and what he does when this situation arises.  Ask him whether he ever gets into physical fights, has been “jumped,” carried a weapon for protection, or used a weapon.  If appropriate, connect him to community-based activities that will keep him off the streets and in a safe environment.

A final word

Risk-taking behavior accounts for the great majority of threats to adolescent males’ physical and mental health.  Uncovering undesirable lifestyle factors is therefore at least as important to the male teenage patient’s well being as a thorough physical examination – which we address in the second and concluding part of this article.  The Level 2-HEEADSSS interview, combined with other psychosocial instruments, developmentally appropriate anticipatory guidance, and educational materials, will help protect the young men in your practice from avoidable morbidity and mortality.

Call Out Page 52

Creating a safe space for confidential conversations

To talk about sensitive topics with male patients, we need to understand our own ideas and stereotypes of males in our society.  These stereotypes are often a source of struggle for the developing adolescent male.  Gender role stereotyping – the belief that all females and males have distinctly different, preordained psychological and behavioral traits and characteristics – still pervades many aspects of American culture.

                The concept of masculinity is socially and culturally constructed and influenced by family, friends, media, religious institutions, and society.  Men in our society are expected to adhere to culturally defined standards for behavior.  Males are socialized to be inexpressive, tough, aggressive, and competitive.  The young man attempting to fulfill this prescribed masculine role may experience “gender role strain,” resulting in shame and humiliation, low self-esteem, and long-term emotional and physical consequences.  Some experts therefore support the development of alternative masculinity ideologies.¹

                With this in mind, you can serve as a positive resource for the adolescent to talk openly about some of the explicit and implicit “strains” of growing up male in the US.  You also can assess a male patient’s specific experiences with masculinity issues and help him to develop in a healthier manner.

                How you phrase questions is important.  A male will express his feelings only If he feels “safe” – that is, not at risk of having his ego damaged.  The best way to explore the patient’s feelings often is not to ask about them directly – at least not initially.  You might say to a young man who has been teased or bullied, for example, “What did you think about that happening to you?” rather than “How did that make you feel?”  Then you can encourage him to describe his emotions.  Similarly, asking the patient “Why did you choose to stop high school?” might be the most effective way to begin a discussion about his feelings about leaving school.

REFERENCES

¹Pleck JH: The gender role strain paradigm: An update. In: Levant RF, Pollack WS (eds): A New Psychology of Men. New York, Basic Books, 1995:11-32

Table 1

The Level II – HEEADSSS psychosocial interview for male adolescents

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Call Out Page 55

RESOURCES

RESOURCES FOR PEDIATRICIANS

Alan Guttmacher Institute.  In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men.  New York, 2002.

www.guttmacher.org/pubs/exs_men.html

Adolescent Health Working Group.  Adolescent Provider Toolkit: A Guide for Treating Teen Patients, Adolescent Health 101: The Basics.

http://ahwg.net/resources/CA101_.pdf

Centers for Disease Control and Prevention.  Youth Risk Behavior Surveillance: United States, 2001. MMWR 2002; 51 (No.SS-4).

www.cdc.gov/mmwr/preview/mmwrhtml/ss5104a1.htm

National Adolescent Health Information Center. A Health Profile of Adolescent and Young Adult Males. http://nahic.ucsf.edu

The Center for Adolescent Health & the Law.  English A, Kenney K: State Minor Consent Laws: A Summary, ed 2, Chapel Hill, NC: Center for Adolescent Health & the Law, 2003. www.cahl.org.  Monograph summarizes state laws that allow minors to give own consent for health care.

Sonenstein FL (ed): Young Men’s Sexual and Reproductive Health: Toward a National Strategy.  Washington, DC: Urban Institute, 2000.  www.urban.org/UploadedPDF/young_mens_health.pdf

McCoy K, Wibbelsnam, C: The Teenage Body Book: Revised and Updated.  NY: Perigee Books, 1999

FOR PARENTS AND PEDIATRICIANS

Ginsburg KR, Jablow MM: But I’m Almost 13!: Raising a Responsible Adolescent.  Chicago: Contemporary Books, 2001

Gurian M:  A Fine Young Man: What Parents, Mentors and Educators Can Do To Shape Adolescent Boys Into Exceptional Men. NY: Penguin Putnam, 1999

Kurcinka MS: Raising Your Spirited Child.  NY: HarperCollins, 1998

Madaras L, Madaras A:  My Body, My Self for Boys, ed 2.  NY: Newmarket Press, 2002

Newberger EH:  The Men They Will Become: The Nature and Nurture of Male Character.  Cambridge, MA: Perseus Publishing, 1999

Pollack WS: Real Boys: Rescuing Our Boys from the Myth of Boyhood.  NY: Owl Books, Henry Holt and Company, 1999

Winbush R: The Warrior Method: A Parent’s Guide to Rearing Healthy Black Boys.  NY: Harper Collins, 2002

Call Out Page 56

Sources for office materials on adolescent male health

OFFICE HANDOUTS

OPA Clearinghouse (free)

opa.osophs.dhhs.gov/pubs/publications.html

ETR Publishing (at cost)

www.etr.org/pub/titles/browse.html

Planned Parenthood (at cost)

www.plannedparenthood.org/teens

OFFICE VIDEOS

Fight for Your Rights – Kaiser Family Foundation/MTV (free)

www.kff.org/entpartnerships/mtv.cfm

Boys Will Be Men (at cost)

www.bullfrogfilms.com/catalog/boys.html

All Men Are Sons (at cost)

www.allmenaresons.com/films/allmenaresons/allmenaresons.html

OTHER RESOURCES

MEDIA LITERACY

Just Think

www.justthink.org

Corporation for Public Broadcasting – Don’t Buy It: Get Media Smart

pbskids.org/dontbuyit/entertainment/makingmusic.html

WORKFORCE SAFETY

U.S. Department of Labor – Youth Rules!

www.youthrules.dol.gov/jobs.htm

(Information about teenagers and jobs)

U.S. Department of Labor – Prohibited Occupations for Non-Agricultural Employees

www.dol.gov/elaws/esa/flsa/docs/haznonag.asp

Information about jobs that teenagers are prohibited from working

DRUG ABUSE

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

www.samhsa.gov; 1-800-662-HELP

CHILD ABUSE, RAPE CRISIS

Childhelp USA® National Child Abuse Hotline

1-800-4-A-CHILD® (1-800-422-4453)

Rape, Abuse and Incest National Network

www.rainn.org  (Provides listing of counseling centers searchable by ZIP code or state)

COSTS OF ADOLESCENT PREGNANCY

It’s Up to Me to Prevent Teen Pregnancy – Budgeting for Baby Game

www.itsuptome.org/myhome/myhome.asp#

Daddy to be – What is the cost of raising a child?

www.family4life.com/daddy2be/d2b_baby_cost.htm

Baby Center – Cost of raising a child calculator

www.babycenter.com/costofchild/index.jhtml?_requestid=124729

GAY, BISEXUAL, AND QUESTIONING MALE

Gay and Lesbian Medical Association – Online Health Care Referrals

http://www.glma.org/

REFERENCES  Page 61

• Goldenring JM, Rosen DS: Getting into adolescent heads: An essential update.  Contemp Pediatr  2004;21(1):64

• Resnick MD, Bearman PS, Blum RW, et al: Protecting adolescents from harm. Findings from the National Longitudinal Study on Adolescent Health.  JAMA 1997;278:823

• Holmbeck GN, Paidoff RL, Brooks-Gunn J: Parenting adolescents. In: Bornstein MH (ed). Handbook of Parenting: Children and Parenting. Mahwah, NJ, Lawrence Erlbaum Associates, 1995:91-118

• Garrity C, Baris MA: Bullies and victims: A guide for pediatricians.  Contemp Pediatr 1996;13(2):90

• Scott J, Hague-Armstrong K, Downes K: Teasing and bullying: What can pediatricians do?  Contemp Pediatr 2003;20(4):105

• Centers for Disease Control and Prevention. BMI – body mass index: BMI for children and teens. http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm. Accessed February 28, 2006

• Barlow SE, Dietz WH: Obesity evaluation and treatment: Expert committee recommendations. The Maternal Child and Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatrics 1998;102:e29

• Centers for Disease Control and Prevention. Overweight children and adolescents: Recommendations to screen, assess and manage. http://www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/module1/text/mainmodules.htm. Accessed February 20, 2005

• Department of Health and Human Services and the Department of Agriculture: Dietary Guidelines for Americans 2005. Washington, DC: US Government Printing Office, 2005, http://www.healthierus.gov/dietaryguidelines

• Johnson W: Nutritional supplements and the young athlete: What you need to know. Contemp Pediatr 2001;18(7):63

• Roberts DF: Media and youth: Access, exposure, and privatization. J Adolescent Health 2000;27(2 Suppl):8

• Rich M: Boy, mediated: Effects of entertainment media on adolescent male health. Adolesc Med  2003;14:691

• American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders, ed 4, rev. Washington, DC: American Psychiatric Press, 2000

• Greydanus DE, Pratt HD, Baxter T: Sexual dysfunction and the primary care physician. Adolesc Med 1996;7(1):9-26.

• Garofalo R, Harper GW: Not all adolescents are the same: Addressing the unique needs of gay and bisexual male youth. Adolesc Med 2003;14:595

• Ryan C, Futterman D: Caring for gay and lesbian teens. Contemp Pediatr 1998;15(11):107

On the Web: Health resources for male adolescents (Pages 62 and 63)

This guide may be photocopied and distributed without permission to give to your patients.  Reproduction for any other purpose requires express permission of the publisher, Advanstar Medical Economics Healthcare Communications. © 2006