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Ask the Experts

Do you work in a Title X-supported agency? If yes, do you have a question about services for males? Submit your question here.

Who are the experts?

Anne Rompalo, M.D., Sc.M.

Arik Marcell, M.D., M.P.H.


Question:

My clinic receives Title X funds and I am confused about when I can count males in my clinic as Title X users. Our clinic sees males for various reasons and to my knowledge their visits are not currently paid for or subsidized by Title X. If a male comes in for STD screening/treatment or any other reason, does he get counted as a Title X user?

Answered By: 

Anne Rompalo and Arik Marcell

Answer:

Every client who walks through the door of a clinic that receives Title X funds is a potential Title X user. Regardless of why a client initially walks in the door and how his visit gets paid for, if he receives family planning services [services that help achieve a desired pregnancy (e.g., reproductive and related preventive health services) or aid in avoiding an unintended pregnancy] during the visit, then he may be counted as a family planning user. The same is true of course for female clients. In order to count a male client as a Title X user, the following criteria must be met:

1) A medical chart is opened for the client.

2) A discussion was held with the client about intent for fatherhood/pregnancy and strategies to achieve healthy pregnancy or avoid unintended pregnancy were included.

3) Method of birth control (including not currently a method) has been selected or identified and recorded.


Question:

A question I am frequently asked is: “My partner has been diagnosed with HPV/cervical/CA. She has had her cervix frozen. Can I reinfect her? What should I do?”

What advice would you give the male partners of women with high grade HPV and abnormal paps who have been treated?

Answered By:

Anne Rompalo and Arik Marcell

Answer:

Even if treated, the type(s) of HPV that cause external warts in the male (e.g. that providers can visualize) may not be the same wart type(s) that cause high grade cervical changes in the female. It is difficult to isolate HPV infection in the male from the urethra or other locations.

There are data that show quicker resolution among women with cervical lesions when their partners consistently where condoms (see reference below). In this study women with CIN and their male sexual partners were randomized for condom use. Women whose partners used condoms showed a 2-year cumulative regression of 53% versus a regression rate of 36% among those whose partners did not use condoms.  This study found that condom use promotes regression of CIN lesions and clearance of HPV.  Other studies also document resolution of flat warts in males whose partners were diagnosed with HPV cervical lesions.

We would thus recommend providers tell their patients to consistently use condoms after a female partner is diagnosed with a high grade HPV lesion. There is a real possibility that reinfection can occur if still having sex with the same partner. Reference Hogewoning CJ, Bleeker MC, van den Brule AJ, et al. Condom use promotes regression of cervical intraepithelial neoplasia and clearance of human papillomavirus: a randomized clinical trial. Int J Cancer. Dec 10 2003;107(5):811-816.

In addition to these criteria, please ensure that every individual seeking family planning services is screened using same income eligibility that your clinic has established regarding the Title X regulations and are appropriately placed on the sliding fee scale. Regardless of the sex of the client, please ensure that each individual is provided confidential services. In addition, for clients that are minors, administrators and providers should be aware of the Title X legislative mandates and regulatory language regarding, but not limited to encouraging family participation in his decision to seek family planning services and you provide counseling on how to resist attempts of coercion into sexual activities and mandatory reporting requirements.


Question:

How do you suggest I counsel a young adult male patient for STI risk reduction?

Answered By:

Arik Marcell, MD, MPH

Answer:

The U.S. Preventive Services Task Force recommends moderate- to high-intensity behavioral counseling in the clinic setting to prevent sexually transmitted infections (STIs) for all sexually active persons.1One example of such a counseling approach would be to schedule two separate 20-minute clinical sessions 1 week apart. During the first clinical session, you should assess your patient’s personal risk, barriers to risk reduction, and identify a small risk-reduction step within the next week that he can realistically make. During the second clinical session, you should review the prior week’s behavioral change successes and barriers, provide support for changes made, identify barriers and facilitators to change, and develop a long-term plan for risk-reduction. A study of this method found that participants in intervention clinics receiving structured behavioral counseling reported significantly higher condom use rates and fewer new STIs than participants at control sites.2Males and females in this study benefited equally from counseling interventions, and brief interventions were more effective among adolescents than older participants.

When counseling for behavior change, determine your patient’s readiness for change. For example, in your situation you can determine how well your patient uses condoms, his barriers when not using condoms and how ready he is improve his condom use behaviors. Example possible counseling strategies are listed below depending on his response to you regarding his stage of change.

If he states that he is not planning to change his condom behaviors…
  1. You can educate him about the importance of condoms in reducing unintended pregnancy and sexually transmitted diseases and advise and encourage him to use condoms.
  2. If he tells you that a barrier to use is decreased pleasure, you can tell him that adding a drop of lubricant inside the condom before he puts it on can help increase stimulation when wearing the condom. In addition, you can tell him that there are many different types and sizes to condoms and that he should see if another brand/size works better for him.
  3. You should also educate him about Emergency Contraception (e.g. Plan B) – many young people do not know about EC. If his partner is not already on a birth control method, he can tell his partner about Plan B after having sex without a condom if indeed they are not planning to get pregnant.
If he states that he is not sure if he will change his condom behaviors…
  • You can explore his ambivalence and ask him what would be steps he would need to take in order to successfully make a change, including reviewing his barriers and facilitators for action.
  • You can also address Points 2 and 3 above.
If he states that he is reading to change his condom behaviors…
  • You can strengthen his commitment and facilitate action.
  • This can include distributing condoms in your clinical office setting.

A number of verbal and written tools are available that can assist health care providers to take a sexual health assessment3and other components of the adolescent’s psychosocial history4, includingthe HEADSS assessment.5, 6When counseling for behavior change, one helpful acronym is FRAMES7which stands for:

  • Provide Feedback on risk/impairment (e.g. it sounds like you are afraid that bringing up condom use at this point in your relationship may make your partner concerned about cheating)
  • Emphasize personal Responsibility for change (e.g. I am here to help you, but it’s very important that you take responsibility for changing things. What steps can you take to help yourself?)
  • Offer clear Advice to change (e.g. I believe the best thing for you would be to…)
  • Give a Menu of options for behavior change and treatment (e.g. You could try X or Y or Z…)
  • Counsel with Empathy (e.g. I know that these things can be very difficult…)
  • Express your faith in the adolescent’s Self-Efficacy (e.g. “I believe in you, and I know that you can do this, when you decide the time is right”; “I want to congratulate you on all the things that you accomplished since our last visit. These things are not easy and you should be very proud of yourself”)

References

  1. Behavioral Counseling to Prevent Sexually Transmitted Infections, Topic Page. U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, Rockville, MD. U.S. Preventive Services Task Force. 2008; www.ahrq.gov/clinic/uspstf/uspsstds.htm.
  2. Kamb ML, Fishbein M, Douglas JM, Jr., et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. JAMA. 1998;280(13):1161-1167.
  3. Monasterio E CN, Warner L, Larsen-Fleming M, St. Andrews A,  Schalet A, Marcell AV, et al. Sexual Health: An adolescent Provider Toolkit. San Francisco, CA: Adolescent Health Working Group, San Francisco. www.ahwg.net; 2010.
  4. Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med. 1999;153(6):591-596.
  5. Goldenring JM, Cohen E. Getting into adolescents heads. Contemporary Pediatrics. July 1988;5(7):75-90.
  6. Marcell AV, Bell DL. Making the most of the adolescent male health visit Part 1: History and anticipatory guidance. Contemp Peds. 2006;23(5):50-63. contemporarypediatrics.modernmedicine.com
  7. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA. Apr 2 1997;277(13):1039-1045.

 


 

 

 

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