CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Emerging Issues in Male Adolescent Sexual and Reproductive Health Care Laura K. Grubb, MD, MPH, FAAP,a Makia Powers, MD, MPH, MSc, FAAP,b COMMITTEE ON ADOLESCENCE

Pediatricians are encouraged to address male adolescent sexual and abstract reproductive health on a regular basis, including taking a sexual history, discussing healthy sexuality, performing an appropriate physical examination, providing patient-centered and age-appropriate anticipatory guidance, and administering appropriate vaccinations. These services can be provided to male adolescent patients in a confidential and culturally appropriate manner, can promote healthy sexual relationships and responsibility, can and involve parents in age-appropriate discussions about sexual health. Departments of aAdolescent Medicine, Pediatrics, and Public Health and Community Medicine, Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts; and bDepartments of Pediatrics and Public Health and Community Medicine, Morehouse INTRODUCTION School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia

During adolescence, several transitions occur for boys, including the Clinical reports from the American Academy of Pediatrics benefit from physical, psychological, and social changes associated with puberty, with expertise and resources of liaisons and internal (AAP) and external 1,2 reviewers. However, clinical reports from the American Academy of most male adolescents reporting the initiation of sexual behavior. Many Pediatrics may not reflect the views of the liaisons or the emerging behaviors, including sexual initiation, are associated with organizations or government agencies that they represent. preventable negative health consequences such as sexually transmitted All clinical reports from the American Academy of Pediatrics infections (STIs), unintended pregnancies, and nonconsensual sexual automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. activity.2 During this developmental period, the number of health encounters typically declines, particularly among older male adolescents, The guidance in this report does not indicate an exclusive course of 3 treatment or serve as a standard of medical care. Variations, taking and there is a shift from routine to more time-limited acute visits. into account individual circumstances, may be appropriate.

Pediatricians and other physicians who care for natal male adolescents DOI: https://doi.org/10.1542/peds.2020-0627 (cisgender or transgender female adolescents) or those who identify as Address correspondence to Laura K. Grubb, MD, MPH, FAAP. E-mail: male (transgender male adolescents or gender nonconforming) have unique [email protected] opportunities to incorporate anticipatory guidance around issues such as PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). puberty and sexuality not only at any health maintenance visits but also at sick and/or injury visits with adolescents and their families. For the Copyright © 2020 by the American Academy of Pediatrics purposes of this report, the term “male” refers to cisgender adolescents and FINANCIAL DISCLOSURE: The authors have indicated they have no young adults, unless otherwise specified.4 financial relationships relevant to this article to disclose. FUNDING: No external funding. Even after the release of the American Medical Association’s Guidelines for Adolescent Preventive Services (GAPS)5 and the American Academy of Pediatrics (AAP) Bright Futures: Guidelines for Health Supervision of Infants, To cite: Grubb LK, Powers M, AAP COMMITTEE ON ADOLESCENCE. Children, and Adolescents,6 which recommend preventive health services for Emerging Issues in Male Adolescent Sexual and Reproductive Health Care. Pediatrics. 2020;145(5):e20200627 adolescents, there have been few improvements in the counseling of male

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 145, number 5, May 2020:e20200627 FROM THE AMERICAN ACADEMY OF PEDIATRICS teenagers regarding the prevention • emerging issues in health lifetime partners, 39% did not use of STIs or HIV infection.7,8 confidentiality; a condom at last sexual intercourse, Furthermore, data from outpatient • data on the patterns of social media and 5% reported initiating sex at 2 medical records reveal that use in male sexual health; 13 years or younger. pediatricians are 3 times more likely • discussion of consent for sexual Adolescents with intellectual to take sexual health histories from acts among adolescents; disabilities (IDs) and physical female than male patients and twice • disabilities are an overlooked group as likely to counsel female patients recommendations for counseling of in terms of sexual behavior, but they on the use of barrier methods.7,9 male adolescents on their roles in contraception decision-making; have similar rates of sexual behaviors Thus, it is important for when compared with their peers • updated data on STIs and pediatricians to have an without disabilities.15 These youth treatment among male patients understanding of what sexual and receive limited sexual education aged 15 to 24 years with updates reproductive health care means for from their parents and pediatricians, on STI screening and treatment; the male adolescent. Although who may assume they will not boys and young men comprise • recommendations on human engage in sexual behaviors.15 Much approximately half of the adolescent papillomavirus (HPV) vaccine for of the research on IDs and sexuality population in the United States, boys; among adolescents and young adults standards for addressing their • information on sexual dysfunction is focused on contraception choices reproductive and sexual health needs among adolescent and young adult and pregnancy prevention among lag behind those for adolescent males and recommendations for females, with little focus on male girls and young women, and addressing in practice; and adolescents. Jahoda and Pownall16 male adolescents continue to be • updated sexual and reproductive evaluated sexual knowledge and a particularly vulnerable patient health resources (Supplemental social networks among adolescents population.7,8 Pediatricians are Table 2) for pediatricians with IDs compared with adolescents encouraged to address male adolescent specifically for male adolescent without IDs. Results revealed that sexual and reproductive health on patients. male adolescents with IDs scored a routine basis, including boys and higher in knowledge of sexual topics young men with developmental or compared with female adolescents physical disabilities,10,11 by taking ADOLESCENT MALE SEXUAL BEHAVIOR with IDs and discussed sexual a sexual history, discussing healthy topics more frequently in their According to the 2017 Youth Risk sexuality, performing an appropriate social networks compared with Behavioral Surveillance System examination, providing patient- female adolescents; however, (YRBSS), 41% of male teenagers of centered and age-appropriate male adolescents with IDs were high school age reported they had anticipatory guidance, performing less likely to have received sexual intercourse, defined as appropriate screening, and information about sex from their opposite-sex vaginal-penile contact, administering vaccinations.12 pediatricians when compared with by the 12th grade.2 In another study, their peers without IDs.16 Current male adolescents were significantly The 2011 AAP clinical report on male research is now being focused more likely to engage in oral sex adolescent sexual and reproductive on the importance of sexuality compared with sexual intercourse health care discusses specific issues counseling with these adolescents and more likely to have significantly related to male adolescents’ sexual and young adults so that they greater numbers of oral sex partners and reproductive health care in the develop healthy sexual behaviors.10 than sexual intercourse partners and context of primary care, including The AAP clinical report “Sexuality indicated that during oral sex, they pubertal and sexual development, of Children and Adolescents had never used STI protection.14 A sexual behavior, masturbation, With Developmental Disabilities” substantial number of young men consequences of sexual behavior, provides additional guidance and report engaging in concerning sexual and methods of preventing STIs information.11 behaviors, including an earlier age of (including HIV) and pregnancy.13 sexual debut and having more sexual As the national dialogue shifts toward This revision provides updated partners than female adolescents.2 openness and acceptance of lesbian, information and recommendations YRBSS data from 2017 indicated that gay, bisexual, transgender, and since the 2011 clinical report, among surveyed male high school questioning (LGBTQ) individuals, including the following: students, 22% reported using adolescents are increasingly • updated information concerning alcohol or drugs before last sexual expressing sexual fluidity and male adolescent sexual behavior; intercourse, 12% reported $4 flexibility. Discordance between

Downloaded from www.aappublications.org/news by guest on October 2, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS sexual attraction and orientation Pediatricians rarely discuss high-risk Association, AAP, Society for and behavior is also possible because sexual behaviors during routine Adolescent Health and Medicine, one’s sexual attraction and sexual adolescent visits, and they discuss American Academy of Family identity do not always predict same-sex sexual behaviors even less Physicians, and American College of sexual behavior.17–19 In the 2017 frequently. Studies have revealed that Obstetricians and Gynecologists.25–29 YRBSS, youth were asked questions pediatricians often do not discuss The 2017 AAP clinical report to ascertain sexual identity and sensitive topics, such as sexual “Sexual and Reproductive Health gender of sexual contacts. Among orientation, sexual identity, gender Care Services in the Pediatric male students, 92% identified identity, violence prevention, or Setting” provides specific guidance as heterosexual or straight, 2% sexual or physical abuse, as part of on the provision of confidential – identified as gay, 3% identified their routine practice.7,9,22 24 These sexual health services.12 The as bisexual, and 3% identified as studies reveal that pediatricians Guttmacher Institute provides not sure. Of male youth who ever who care for adolescents are not updated summaries of states’ had sexual intercourse, 80% routinely asking about sexual consent and confidentiality laws reported having sexual contact practices and the sexual orientation for minors on its Web site.30 with the opposite sex only and 76% of their patients, preventing them reported having sexual contact from adequately addressing sexual The expansion of electronic health with the same sex only or both health concerns and sexual risk. records and the increased coverage of sexes. Fifty-nine percent of high LGBTQ teenagers and young adults young adults (up to age 26) through school students denied any history are an underserved population, their parents’ insurance plans have of sexual contact.2 many of whom struggle with presented additional challenges to acceptance of their sexuality while confidentiality. Although the Health Although most LGBTQ youth are they are managing the other rigors Insurance Portability and resilient and emerge from of adolescence. It is important Accountability Act of 199631 provides adolescence as healthy adults, the that pediatricians and other protection of private health effects of homophobia and physicians obtain the skills needed information from some disclosures, it heterosexism can contribute to to provide culturally effective, also allows disclosure of information concerning health issues for sexual developmentally appropriate care for the purpose of treatment, minority youth (those who identify as for sexual minority youth. The payment, or health care operations gay, lesbian, or bisexual; those who 2013 AAP policy statement “Office- with consent.32 Adolescents are at are not sure about their sexual Based Care for Lesbian, Gay, risk for confidentiality breaches when identity; or those who have sexual Bisexual, Transgender, and insurers send explanations of benefits contact with only the same sex or Questioning Youth” provides or denials of claims to policyholders with both sexes). Sexual minority additional guidance.20 after anyone covered under their youth, in comparison with policy obtains care. These insurance heterosexual adolescents, have higher documents may identify the rates of depression and suicidal EMERGING ISSUES IN HEALTH individual who received care, the CONFIDENTIALITY ideation, higher rates of substance health care provider, and the type of abuse, and riskier sexual behaviors.20 Adolescents’ right to consent and care obtained. In 2014, the AAP, Sexual minority boys and young men confidentiality and health care are American College of Obstetricians and reported significantly higher rates of intertwined. Providing confidentiality Gynecologists, and Society for violence-related behaviors, including supports adolescents in their Adolescent Health and Medicine being forced to have sex, school development of autonomy and plays released a policy statement on the bullying, and being victims of physical a significant role in their willingness importance of confidentiality and/or sexual dating violence.21 to access necessary health care or protections in the insurance billing Sexual minority boys and young men disclose important information to process.33 The AAP also reported higher rates of earlier pediatricians. There is no federal law also recommended confidentiality sexual debut, $4 sexual partners, less that explicitly protects adolescents’ protections in its 2012 policy barrier-method use, less right to confidential health care. statement “Standards for Health contraceptive use when engaged in There are individual state laws, and Information Technology to Ensure intercourse with female partners, and numerous international and national Adolescent Privacy.”34 This guidance higher use of drugs or alcohol before organizations have outlined the provides pediatricians with sexual intercourse compared with importance of confidentiality a framework to provide their non–sexual minority protections, including the United confidentiality while delivering counterparts.21 Nations, American Public Health important adolescent services.

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 145, number 5, May 2020 3 USE OF MEDIA AND SOCIAL MEDIA enhanced breasts), normalization victims are responsible for their Adolescents use a variety of media to of aggressive or violent sexual acts assaults, that male sexual assault and violence, and a lack of emotional victims experience less trauma than socialize and learn about and engage 40 in sexual activity. Media uses include intimacy between actors. During their female counterparts, and that television, video games, social media, the social history, pediatricians can ejaculation is an indicator of texting, smart phone applications, screen for social media use, a positive experience. As a result ’ Web sites, and online pornography. pornography viewing, patients of these misbeliefs, there is an Boys are more likely than girls to perceptions of such material, and underreporting of sexual assaults by make online friends and any adverse effects and provide male victims, a lack of appropriate communicate with them online rather guidance on safe and sensible services for male victims, and less than in person.35 Recent studies of Internet and social media use to legal redress for male sexual assault adolescents revealed that male parents and patients. The AAP victims. By comparison, male sexual participants were statistically more provides policies, information, assault victims have fewer resources ’ likely to receive sexually explicit texts advice, and resources about families and greater stigma than do female ’ 45 and be sexually active and that sexual and children s interactions with sexual assault victims. Pediatricians various forms of media on its are encouraged to ask male patients minority male youth were more likely 41,42 to send sexually explicit texts than Web site. about exposure to sexual assault female adolescents.36,37 In a recent (and other types of victimization) study examining “sextortion” (the SEXUAL ASSAULT AND CONSENT FOR during the social history of routine threatened dissemination of explicit, SEXUAL ACTIVITY health supervision visits. When exploring alcohol or substance use, intimate, or embarrassing images of Sexual assault is a prevalent issue it is important to discuss the link a sexual nature without consent, that can affect many adolescents, between impairment and usually for the purpose of procuring regardless of gender. Until 2012, vulnerability to sexual assault. additional images, sexual acts, published US Federal Bureau of It is advised that adolescents who money, or something else) of US Investigation annual crime data disclose a previous assault be asked middle and high school students, defined “forcible rape” as “the carnal about the dynamics of their researchers found that boys and knowledge of a female forcibly and relationships (eg, exploitative, sexual minority youth were more against her will.”43 As a result of controlling, nonconsensual). The likely to be targeted and that boys this definition, there are limited 2017 AAP clinical report “Care of were more likely to target other data concerning sexual assault of 38 the Adolescent After an Acute Sexual youth. male victims and even less Assault” provides additional information for male adolescents.44 Of concern to pediatricians is guidance.46 In addition to being In the 2017 YRBSS report, 3.5% of frequent adolescent exposure to victims of sexual assault, there have male high school students disclosed pornography. In one study, more than been many high-profile founded ever being physically forced to have half of male youth Internet users 14 and unfounded cases of sexual assault sexual intercourse, of whom 3% to 15 years of age had been exposed by boys and young men resulting identified themselves as heterosexual, to either unwanted or wanted online in significant disruption in the 16% as LGBTQ, and 12% as unsure of pornography in the past year, as victims and alleged perpetrators’ their sexual orientation. Male victims had more than two-thirds of those lives and futures. In the United States, who experienced sexual violence 16 to 17 years of age. Thirty-eight of people arrested or convicted of reported the sex of their sexual percent of male Internet users aged sexual assault, 96% to 99% are male. contacts as the following: 4% 16 to 17 intentionally visited Overall, an estimated 9% of the 39 opposite sex only, 26% same sex pornographic sites in the past year. victims of rape and sexual assault only or both sexes, and 1% no There are conflicting data concerning were cisgender male. Nearly 99% sexual contact. In the same report, the effects of pornography. Some of the offenders described in single- 4.3% of male high school students studies reveal that users report victim incidents were male. In the reported experiencing any sexual positive effects on sexual health United States, per capita rates of violence.2 whereas others report negative rape/sexual assault were found to effects, and there is no conclusive For male victims of sexual assault, be highest among residents aged information concerning sexual there are significant stigmas to 16 to 19 years, demonstrating tha function or dysfunction. Pornography reporting the assault, including the youth are particularly vulnerable.47 frequently portrays male and female misperceptions that males in inequalities, specific body types noninstitutionalized settings are Each state has its own statutes (thin women with surgically rarely sexually assaulted, that male regarding consent, rape, and sex

Downloaded from www.aappublications.org/news by guest on October 2, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS crimes, and each college or institution “no”; assuming that wearing certain contraception and the association may have its own set of policies clothes, flirting, or kissing is an with shared decision-making.52 concerning sexual consent.48 The US invitation for anything more; Richards et al52 recruited 93 Department of Justice provides the someone being younger than the ethnically diverse adolescent men to following definitions: “Rape - Forced legal age of consent (as defined study their knowledge of emergency sexual intercourse including both by the state); someone being contraception (EC). Their findings psychological coercion as well as incapacitated because of drugs revealed that fewer than half of the physical force. Forced sexual or alcohol; pressuring someone young men had ever heard of EC. intercourse means penetration by the into sexual activity by using fear Those who were aware of EC were offender(s). Includes attempted or intimidation; and assuming more likely to be older (median rapes, male as well as female victims, permission to engage in a sexual 19.7 years), have knowledge of and both heterosexual and same sex act because it has occurred in the other contraceptive methods, and rape. Attempted rape includes verbal past. Pediatricians are encouraged participate in shared contraceptive threats of rape. Sexual assault - A to include discussions of definitions decision-making with their partners. wide range of victimizations, separate and understandings of sexual The most recent literature review from rape or attempted rape. These consent, dispel myths concerning regarding EC-related knowledge, crimes include attacks or attempted consent, and provide anticipatory attitudes, and behaviors among attacks generally involving unwanted guidance concerning consensual men revealed that male adolescents sexual contact between victim and sexual activity to facilitate safe have lower knowledge of EC than offender. Sexual assaults may or may and healthy relationships their adult male counterparts and are not involve force and include such between male adolescents and less likely to have had a partner use things as grabbing or fondling. It their partners. this form of contraception.53 This also includes verbal threats.”49 study reveals the importance of There is no standard definition PREGNANCY PREVENTION AND counseling young men on all of consent, and many institutions CONTRACEPTION COUNSELING contraceptive methods to promote have attempted to define and increased usage. According to the 2011–2015 National implement policies concerning Survey of Family Growth, 84% of Once it is determined that an sexual consent. The Department sexually experienced cisgender male adolescent is at risk for pregnancy, of Justice of the Government of teenagers reported using the pediatrician may take the Canada defines sexual consent for contraception at first sexual opportunity to provide counseling the purposes of sexual assault intercourse.1 These rates varied by regarding all forms of contraception offenses as “the voluntary agreement the age of the male at first sex: boys and each method’s effectiveness in of the complainant to engage in the who were 14 years and younger had pregnancy prevention. If there is not sexual activity in question. Conduct lower rates of contraception use at time during a routine or sick short of a voluntary agreement first sex than did males who were 17 appointment, the pediatrician can to engage in sexual activity does to 19 years of age (71% and 95%, schedule follow-up appointments not constitute consent as a matter respectively).1 Ninety percent of male specifically to discuss pregnancy of law.”50 teenagers used some method of prevention and contraception options. Contraception counseling is When discussing sexuality, contraception, including withdrawal relevant for heterosexual and sexual pediatricians can address issues of at last sex, with 61% reporting using minority youth because LGBTQ youth consent during anticipatory guidance condoms at last sex, 19% reporting are at a higher risk for unintended if sexual screening warrants concern. some contraceptive pill use, and 35% pregnancies than their heterosexual Additionally, pediatricians can reporting a dual method (hormonal 2 peers.54 Transgender men or encourage patients to communicate and barriers). transmasculine people can with partners concerning sexual The male adolescent can play an themselves be at risk for pregnancy activity before engagement by important role in the couple’s (and require contraceptive counseling respecting verbal and nonverbal contraception decision-making. In if appropriate), and transgender boundaries and cues, emphasizing many cases, male adolescents prefer women or transfeminine people may that consent should occur with each their partners to involve them in have male genitalia and require activity every time and that parties discussions of contraception appropriate counseling about their may change their minds. Pediatricians methods.51 Over the past decade, risk of causing pregnancy. can educate male youth that the there has been a growing body of following situations do not involve evidence regarding young men’s Male adolescents can play a vital role consent: refusing to acknowledge knowledge of various forms of in pregnancy prevention and

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 145, number 5, May 2020 5 contraceptive decision-making in From 2016 to 2017, the CDC reported for uncomplicated gonococcal their female partners. Pediatricians substantially large increases for infections.61 can encourage male adolescents to syphilis, gonorrhea, and chlamydia attend contraceptive visits with their for both men and boys aged 15 to There continues to remain significant partners. During these visits, there is 24 years.56 underscreening of youth for STIs in 62,63 a great opportunity to elicit the pediatric setting. This pregnancy desires and/or intentions In 2017, males aged 13 to 24 years underscores the need for of the couple and to educate them on accounted for 17.5% of all new HIV pediatricians to offer screening based a variety of contraceptive methods diagnoses in the United States and on risk assessment, appropriate and the importance of shared 87% of all diagnoses among young treatment, and review strategies for decision-making. Additionally, the people aged 13 to 24 years. Most of prevention of transmission to reduce provider can encourage the male those new HIV diagnoses among STI incidence and morbidity among partner to commit to consistent youth (81%) were attributed to male- all adolescents. The CDC recommends condom use as a way to have to-male sexual contact.57 Young that clinicians consider screening for personal control over unplanned people (aged 13–24 years) accounted chlamydia in clinical settings serving pregnancy. If the male adolescent for an estimated 21% of all new populations of young male patients becomes a father, either through HIV diagnoses in the United States with a high prevalence of chlamydia intended or unintended pregnancy in 2017, totaling 8164 people, of (eg, adolescent clinics, correctional with his partner, he will require which 87% were in natal males and facilities, and STI clinics). The CDC unique social supports during the 13% were in natal females.2 Also, the does not recommend the routine journey of fatherhood. These needs study revealed that 25% of screening of adolescents who are are the focus of the AAP clinical transgender women were living asymptomatic for certain STIs (eg, report “Care of Adolescent Parents with HIV, and the percentage of syphilis, trichomoniasis, bacterial and Their Children.”55 transgender people who received vaginosis, herpes simplex virus, HPV, a new HIV diagnosis was more hepatitis A, and hepatitis B) but does than 3 times the national average recommend screening for syphilis in STIS, SCREENING, AND TREATMENT 61 in 2015.58 In 2017, 1122 youth males who have sex with males. The RESISTANCE received a diagnosis of AIDS, US Preventive Services Task Force Adolescents continue to face the representing 8% of total AIDS concludes that the current evidence is greatest risk of acquiring STIs and not diagnoses that year.2 insufficient to assess the balance of receiving appropriate care for STIs benefits and harms of routine because of insufficient screening, There has been an increase in the screening for chlamydia and confidentiality concerns, lack of incidence of Neisseria gonorrhoeae gonorrhea in boys and men.64 For access to health care, and multiple infections among male adolescents, males who have had sex with males, sexual partners. Most cases continue particularly among males who have the CDC recommends at least annual to go undiagnosed and untreated, sex with other males.59 During 2013 screening for HIV, syphilis, gonorrhea putting individuals at risk for severe to 2017, the rate of N gonorrhoeae at all sites of contact (by using urine, and often irreversible health infection among male patients rectal, and pharyngeal sampling), and consequences, including infertility, increased 86.3%, compared with the chlamydia on urine and rectal chronic pain, and increased risk for rate increase among female patients sampling (testing for chlamydia HIV as well as the propagation of STIs of 39.4%.59 The 2016 Gonococcal pharyngeal infection is not in the population. Youth aged 15 to Isolate Surveillance Project revealed recommended) regardless of barrier- 24 years comprise 27% of the significant antibiotic resistance to method use. More frequent STI sexually active population in the gonococcal infections, and isolates screening (ie, for syphilis, gonorrhea, United States but account for more from males who have sex with males and chlamydia) at 3- to 6-month than 50% of new cases of STIs each are more likely to exhibit intervals is indicated for males who year.56 According to the Centers for antimicrobial resistance than isolates have sex with males if risk behaviors Disease Control and Prevention from males who have sex with persist or if they or their sexual (CDC), youth account for the majority females.60 With increasing partners have multiple partners.61 of new cases of gonorrhea, chlamydia, cephalosporin-resistant gonorrhea, Given the significant increases in all HPV, and genital herpes and nearly the CDC recommended in 2012 STIs among male patients in the past one-quarter of new cases of HIV exclusive parental high-dose 5 years, it is reasonable for and syphilis annually. In this section, ceftriaxone treatment (250 mg, pediatricians to maintain a high index CDC data refer to cisgender male intramuscular) and a second of suspicion for STIs and consider patients, unless otherwise stated. antibiotic (azithromycin, 1 g) testing for male patients who are

Downloaded from www.aappublications.org/news by guest on October 2, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS FIGURE 1 Bright Futures medical screening reference table: adolescence visits (11 through 21 years). (Reprinted with permission from American Academy of Pediatrics. Bright Futures medical screening reference table: adolescence visits [11 through 21 years]. Available at: https://brightfutures.aap.org/Bright% 20Futures%20Documents/MSRTable_AdolVisits_BF4.pdf. Accessed June 9, 2019.)

sexually active. Bright Futures encouraged for all sexually active individuals with a high number of provides a risk assessment to assist adolescents and those with other risk sexual partners), the CDC with screening decisions (Fig 1).65 factors for HIV.68 Additionally, the recommends preexposure CDC recommends routine HIV prophylaxis (PrEP) to reduce HIV Only 10% of high school students screening for all patients seeking acquisition and transmission.69 As of have been tested for HIV, and among treatment of STIs, including all this publication, the US Food and male students who have had sexual patients attending STI clinics, during Drug Administration has approved 2 contact with other males, only 21% each visit for a new complaint medications, emtricitabine (200 have ever been tested.57 The AAP, in regardless of whether the patient is mg)/tenofovir disoproxil fumarate Bright Futures,7 the Red Book,66 and known or suspected to have specific (300 mg) and emtricitabine (200 a policy statement,67 recommends behavior risks for HIV infection.69 For mg)/tenofovir alafenamide (25 mg), that routine screening be offered to individuals at increased risk for HIV for PrEP in adolescents and all adolescents at least once by 16 to acquisition (sexually active males adolescents who weigh at least 35 18 years of age in health care settings who have had sex with males, kg.70,71 TheCDCWebsiteprovides when the prevalence of HIV in the individuals with an HIV-positive an HIV risk behavior assessment, patient population is more than 0.1%. partner, individuals participating in PrEP clinical practice guidelines, In areas of lower community HIV anal intercourse, individuals having patient and provider education, and prevalence, routine HIV testing is frequent sex without a condom, and tool kits.72

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 145, number 5, May 2020 7 The CDC publishes treatment United States.77 Beginning in a sexual problem, using the validated guidelines for STIs, including December 2014, after US Food and surveys the International Index of recommendations for special Drug Administration approval of the Erectile Function and the Premature populations such as adolescents, 9-valent HPV vaccine (which provides Ejaculation Diagnostic Tool. On the people in correctional facilities, males additional protection against HPV-31, International Index of Erectile who have sex with males, and HPV-33, HPV-45, HPV-52, and HPV- Function, respondents indicate transgender men and women.57 58), use of the quadrivalent HPV agreement with 15 items used to Effective clinical management of vaccine has been slowly phased out.78 assess erectile function, orgasmic patients with treatable STIs includes In October 2016, the Advisory function, sexual desire, intercourse treatment of the patients’ current sex Committee on Immunization satisfaction, and overall satisfaction.82 partners to prevent reinfection and Practices updated its recommended These problems are more prevalent reduce further transmission. dosing schedule for routine HPV than previously believed and cause Expedited partner therapy (EPT) can vaccination to a 2-dose series for significant distress to young men. be a particularly useful option to adolescents initiating vaccination The most common sexual problems facilitate partner management for before their 15th birthday on the among young men include premature adolescents who are diagnosed with basis of available immunogenicity ejaculation (PE) (20%) and erectile chlamydia or gonorrhea. The CDC’s evidence indicating that a 2-dose disorder (ED) (45%). Other common Web site provides guidance, schedule (0 and 6–12 months) has an problems included low sexual a provider tool kit, and a summary of efficacy equivalent to a 3-dose satisfaction (48%) and low desire states’ EPT laws.73 schedule (0, 1–2, and 6 months) if the (46%).80,81 HPV vaccination series is initiated before 15 years of age.78 In a 2-dose PE is a persistent or recurrent pattern HPV AND VACCINE RECOMMENDATIONS schedule of the HPV vaccine, the of ejaculation occurring during fi partnered sexual activity within HPV is the most common STI in the minimum interval between the rst 78 approximately 1 minute after United States, with almost every and second doses is 5 months. In clinical trials for male subjects, penetration and before the person person acquiring an HPV infection at wishes it.83 In a Swiss study of some time in their life.74 The most the most common adverse events were injection-site reactions (most men aged 18 to 25 years, 11% common clinical manifestation of 84 of which were mild or moderate reported PE. This and another HPV is warts, and the most prevalent study revealed an association high-risk (oncogenic) types are in intensity), headache, and fever. Still, male adolescent HPV vaccination between PE and poor physical health, HPV-16 and HPV-18. Persistent alcohol consumption, illegal drug infections with high-risk HPV types rates continue to be low compared with other adolescent vaccination use, tobacco use, and less sexual can cause cervical, vaginal, and experience.84,85 vulvar cancers in natal women, rates or female HPV vaccination penile cancers in natal men, and rates. In the United States, male ED is marked difficulty in obtaining oropharyngeal and anal cancers HPV vaccination coverage with at an erection during sexual activity, in both men and women.75 least 1 dose was 63%, and 53% marked difficulty in maintaining an Approximately 9100 US men each of boys ages 13 to 17 years were erection until the completion of year receive a diagnosis up to date with the recommended 79 a sexual activity, or marked decrease of oropharyngeal cancer caused by HPV vaccination series. The in erectile rigidity.83 ED prevalence fi HPV infection.75 During 2013 to modi ed schedule for younger among young men 18 to 25 years 2014, oral and genital HPV adolescents may improve rates, old approaches 30%.84 Poor mental prevalence among adults 18 to and pediatricians are uniquely health, depression, and consumption 59 years of age was significantly situated to address the lag in HPV of medication without prescription higher for men than women. vaccination rates among adolescent were predictive factors for ED. There are no data currently boys and young men. ED persistence was also associated available for boys younger than with having multiple sexual 85 18 years. Males who have sex SEXUAL DYSFUNCTION partners. with males are at particularly high risk for HPV-mediated anal Healthy sexual function has an When pediatricians identify health cancers.76 important role in the well-being and issues such as mental health problems, development of adolescents and physical inactivity, substance use, or In 2006, the CDC Advisory Committee young adults.80,81 A 2016 study of multiple sexual partners, they may on Immunization Practices first sexually active males aged 16 to consider these an indication to screen recommended the HPV vaccine in the 21 years revealed that 79% reported for sexual dysfunction. Pediatricians

Downloaded from www.aappublications.org/news by guest on October 2, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Sexual Dysfunction Among Male Adolescents have an opportunity to screen for System Medical Condition problems with sexual functioning, Cardiovascular Moderate to mild valvular disease to offer reassurance or treatment, or Uncontrolled hypertension to appropriately assess for an underlying medical condition. Young Endocrine Addison disease patients often will not spontaneously Diabetes mellitus discuss these topics because of Hyperprolactinemia Hyperthyroidism embarrassment, pride, or masculinity Hypothyroidism or confidentiality concerns, so the Klinefelter syndrome onus is on the pediatrician to screen Low testosterone level for sexual problems.85,86 In screening for sexual problems, pediatricians Genitourinary Congenital hypospadias Epispadias may want to explore whether male Pelvic trauma patients have unrealistic expectations Priapism or misinformation concerning sex and sexual activity. When discussing Hematologic Sickle cell disease medications with patients, Infections Prostatitis pediatricians should discuss sexual STIs dysfunction as an adverse effect and screen for sexual dysfunction Neurologic Back injury in patients taking medications Brain injuries, lesions, or tumors routinely or on a long-term basis. Craniopharyngioma fi Epilepsy Conversely, identi cation of sexual Multiple sclerosis dysfunction is an indicator to Peripheral neuropathy screen for other health problems Spinal cord injury (Table 1). Stroke Even when patients do not initiate Other medical conditions Chemotherapy Chronic infections this conversation, they may still be Chronic medical diseases receptive to screening from their Eating disorders pediatricians, who may use Excessive wt loss or gain standardized tools such as the Major or general surgery International Index of Erectile Malnutrition Obesity Function 5 and the Premature Obstructive sleep apnea Ejaculation Diagnostic Tool, which Radiation were validated to screen men Restless legs syndrome 18 years and older.87,88 When male fi Other conditions patients are identi ed as having Psychological and mental Abuse: sexual, physical, emotional sexual dysfunction, a complete health Environmental: lack of privacy, timing medical and psychosocial history Fatigue and physical examination, including Guilt or shame genital examination with sexual Mood disorders: anxiety, depression, bipolar Misconceptions about normal functioning maturity rating, are essential to Partner anxiety or sexual dysfunction evaluation to assess for any medical Performance anxiety issues that can be worked up Relationship problems and addressed (Table 1).89,90 Sexuality concerns, gender dysphoria Pediatricians may also screen Substance use: illicit drugs, alcohol Trauma patients concerning illicit use Unrealistic expectations of any medications or supplements (prescription as well as over the Substances and medications Alcohol counter), including pharmacologic Amphetamines agents for ED and performance- Antiandrogens (spironolactone) enhancing substances (ie, 3,4- methylenedioxymethamphetamine or supplements) because unmonitored

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 145, number 5, May 2020 9 TABLE 1 Continued of sexual and reproductive health System Medical Condition care into their practices and to Antidepressants, particularly selective serotonin reuptake provide guidance on overcoming inhibitors barriers to providing this care Anti-hypertensives:b-blockers, clonidine, guanethidine, methyldopa routinely while maximizing Antipsychotics opportunities for confidential health Cimetidine services delivery in their office.5 Illicit substances Ketoconazole TheAAPhasissuedapolicy Opioids statement on refusal to provide Prescription medication misuse information or treatment on the Steroids basis of conscience. According to Thiazides, particularly chlorthalidone the policy, pediatricians have Adapted from Rew KT, Heidelbaugh JJ. Erectile dysfunction. Am Fam Physician. 2016;94(10):822. a duty to inform their patients about relevant, legally available use may pose health risks and has health-initiatives/Mental-Health/ treatment options to which they been associated with increased risky Pages/Key-Resources.aspx). object, and they have a moral sexual behavior.91 obligation to refer patients to other physicians who will provide and Several studies in men older than CONCLUSIONS educate about those services. Failure 18 years revealed statistically Pediatricians are in the best position to inform and educate about significant improved self-esteem, to deliver high-quality sexual and availability and access to these mood, sexual function, sexual reproductive health care services to services violates this duty to their relationship health, orgasmic male adolescents and can view even adolescent and young adult function, sexual desire, and 95 follow-up, acute care, and patients. intercourse satisfaction among those, immunization visits as opportunities including young men, who received to address these health issues. GUIDANCE FOR PEDIATRICIANS short-term (maximum 8 attempts Although time constraints at most with medication) pharmacotherapy 1. Discuss sex and sexuality with all 80,92,93 adolescent visits may preclude a full for ED. In treating sexual exploration of many issues male adolescents during routine dysfunction, having an established surrounding sexuality in adolescents, visits and more frequently, as and ongoing provider-patient additional visits can be scheduled to appropriate, and screen for sexual relationship and addressing address identified issues. activity and high-risk sexual mental health concerns, including activity at routine visits and other “ substance use, may be crucial Pediatricians can also use clinical appropriate opportunities; therapeutic measures. Follow-up hooks,” such as preparticipation 2. screen adolescents for social therapy may need to include physical evaluations or acne follow- media use (especially sexually mental health services, relaxation up, to keep male adolescents explicit material), pornography techniques, and a discussion of engaged in care and to deliver sexual viewing, perceptions of such the skills needed to assist the and reproductive health care material, and any adverse effects adolescent in achieving some services. Staying informed on and provide guidance on safe degree of voluntary control of different issues of sexuality and and sensible Internet and social sexual function. sexual behaviors, initiating these media use to parents and patients conversations with male patients, during the social history of well It is important that pediatricians and being prepared to provide visits; familiarize themselves with available appropriate anticipatory guidance counseling services within their are best practices when taking care 3. screen for nonconsensual sexual communities for adolescents and of male adolescents.12 The AAP activity and discuss principles of young adults. This clinical report does publications “Sexual and sexual consent and nonconsent not contain explicit recommendations Reproductive Health Care Services in during well visits as well as other for mental health services, but the Pediatric Setting” and “Targeted visits, as appropriate; pediatricians can consult AAP Reforms in Health Care Financing 4. coach male adolescents on how to resources for more direction, such as to Improve the Care of Adolescents talk with their partners about sex the Key Resources of the Mental and Young Adults”94 provide and family planning, encourage Health Initiative (https://www.aap. a framework to assist pediatricians joint decision-making between org/en-us/advocacy-and-policy/aap- in incorporating various aspects partners about sexual and

Downloaded from www.aappublications.org/news by guest on October 2, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS reproductive health matters, and patients with sexual dysfunction, Geri Hewitt, MD - American College of encourage use of both screen male patients with health Obstetricians and Gynecologists contraception and barrier and mental health issues for sexual Seema Menon, MD - North American Society of Pediatric and Adolescent Gynecology methods, as appropriate; problems, and follow-up with Lauren B. Zapata, PhD, MSPH - Centers for 5. provide routine STI risk patients who report sexual Disease Control and Prevention assessment screening for all male problems and consider therapies such as counseling or patients and appropriate testing STAFF for STIs, including HIV, syphilis, pharmacotherapy, as appropriate. chlamydia, and gonorrhea, when Karen Smith James Baumberger, MPP warranted and on request and LEAD AUTHORS provide appropriate STI treatment, Laura K. Grubb, MD, MPH, FAAP including prevention therapy Makia E. Powers, MD, MPH, FAAP and EPT; ABBREVIATIONS 6. consider HPV vaccination for boys COMMITTEE ON ADOLESCENCE, 2019–2020 starting at age 9 years, provide AAP: American Academy of routine vaccination for all Elizabeth M. Alderman, MD, FSAHM, FAAP, Chairperson Pediatrics adolescent boys at age 11 years, Richard J. Chung, MD, FAAP CDC: Centers for Disease Control and aim for complete HPV Laura K. Grubb, MD, MPH, FAAP and Prevention vaccination for all male patients, Janet Lee, MD, FAAP EC: emergency contraception Makia E. Powers, MD, MPH, FAAP and emphasize the importance of ED: erectile disorder complete HPV vaccination for male Krishna K. Upadhya, MD, FAAP Stephenie B. Wallace, MD, MSPH, FAAP EPT: expedited partner therapy patients who participate in high- HPV: human papillomavirus risk behaviors; and ID: intellectual disability PAST COMMITTEE MEMBERS 7. provide screening for sexual LGBTQ: lesbian, gay, bisexual, problems with all sexually active Cora C. Breuner, MD, MPH, FAAP, Former transgender, and male patients as part of the well Chairperson questioning visit sexual history and at other Laurie L. Hornberger, MD, FAAP PE: premature ejaculation appropriate visits, consider the PrEP: preexposure prophylaxis use of standardized screening LIAISONS STI: sexually transmitted infection tools for sexual dysfunction, Liwei L. Hua, MD, PhD - American Academy YRBSS: Youth Risk Behavioral investigate further for other health of Child and Adolescent Psychiatry Surveillance System or mental health issues in male Ellie Vyver, MD - Canadian Pediatric Society

Drs Grubb and Powers, along with the Committee on Adolescence, researched, conceived, designed, analyzed and interpreted data for, drafted, and revised this clinical report; and all authors approved the final manuscript as submitted.This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on October 2, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS 93. Olsson AM, Speakman MJ, Dinsmore 94. Marcell AV, Breuner CC, Hammer L, 95. Committee on Bioethics. Policy WW, et al; Sildenafil Multicentre Study Hudak ML; Committee on Adolescence; statement–physician refusal to provide fi Group. Sildena l citrate (Viagra) is Committee on Child Health Financing. information or treatment on the basis effective and well tolerated for treating Targeted reforms in health care erectile dysfunction of psychogenic or financing to improve the care of of claims of conscience. Pediatrics. mixed aetiology. Int J Clin Pract. 2000; adolescents and young adults. 2009;124(6):1689–1693. Reaffirmed 54(9):561–566 Pediatrics. 2018;142(6):e20182998 June 2018

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 145, number 5, May 2020 15 Emerging Issues in Male Adolescent Sexual and Reproductive Health Care Laura K. Grubb, Makia Powers and COMMITTEE ON ADOLESCENCE Pediatrics 2020;145; DOI: 10.1542/peds.2020-0627 originally published online April 27, 2020;

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