Finding a segue into sex: young men’s views on discussing sexual health with a GP

One Australian study found that less than 10% of GPs took a sexual history from young heterosexual patients, and that female GPs were more likely to take a sexual history from young, heterosexual patients than were male GPs.⁴ A well-known barrier for GPs taking a sexual history is fear of patient embarrassment,^4–7 although there has been minimal research undertaken to confirm this concern from the patient’s perspective. It is also known that GPs are more confident to bring up sexual health when it is obviously related to the patient’s presenting complaint (eg. genital symptom, post exposure to STI).⁷

The developmental stage of young men may explain their vulnerability in regard to sexual health. It is known that risk-taking behaviour peaks at around 15–16 years of age, and that the cognitive centres responsible for impulse control do not fully mature until about the age of 25 years.⁸ Thus, young people, and young men in particular, tend to make impulsive, emotional decisions without thinking through the consequences.⁸

Many young people will seek sexual health information from various sources. The media and websites are trusted by few as a reliable source of sexual health information, but are used by about one-third of young people.¹ Doctors are felt to be a trusted source of sexual health information by more than 80% of young people; however, only about one-third of young people seek such advice from them.¹

To optimise the ability of GPs to improve the sexual health of young men, more research investigating the knowledge and attitudes of young men to sexual health and GPs is required. The aim of this study is to explore the research question ‘Do young Victorian men feel comfortable talking about sexual health with a GP?’.

Methods

This study used a qualitative research design to explore viewpoints of young men. Semi-structured interviews were conducted with young men aged 16–25 years, recruited from two educational institutions. Participants from a variety of classes were invited to take part in interviews after a brief explanation of the research study by the interviewer. The participant either contacted the interviewer to arrange an interview, or self presented to a designated interview room. Potential participants were excluded if they met exclusion criteria as shown in Table 1. Participant demographics are shown in Table 2. Individual interviews were conducted to allow confidential exploration of perspectives on sexual health. Using purposive sampling, 15 university students were recruited from various faculties, and 16 younger participants were recruited from a TAFE following a Mature Minor assessment.⁹

Data collection

In total, 31 interviews were conducted: 16 TAFE students by SL in April 2013 and 15 university students by AC in October 2012. Interviews were conducted in a private room and audio-recorded. The pseudonyms used were chosen by the participants themselves. An interview schedule was used to promote discussion and covered topics such as desired sexual health information, knowledge of contraception and STIs, and whether they would initiate or carry on a conversation on sexual health with a GP. To satisfy the ethical standards of the educational institutions from which we recruited participants, questions were not directed at the personal experience of the young men. Rather, the line of questioning was around what the young men thought was the predominant view of their peer group, although some participants chose to disclose personal experiences.

Data analysis

All interviews were transcribed and Microsoft Word was used for data management. Thematic analysis was applied to the data, initially by blocking, grouping and labelling followed by secondary analysis to identify emerging themes. Analyst triangulation was utilised and consensus on themes was reached by the study team, each of whom has a different disciplinary background.

Results

It was apparent that many of the young men had not given much thought to sexual health before the interview. The university students used more sophisticated language than the younger, TAFE students. Common themes emerging through the interviews regardless of education or age included the views of young men on GPs discussing sexual health and the vulnerability of young men in regard to sexual health. This vulnerability was due to lack of information on contraception and STIs, apathy toward sexual health matters and immaturity in regard to decision making.

Young men’s views on discussing sexual health with a GP

Almost all the young men felt it would be acceptable for the GP to bring up sexual health in an unrelated consultation, provided it was done in an appropriate manner and that the presenting complaint was not serious. The few who were not happy for the GP to bring up sexual health were unaware that STIs could be asymptomatic. Nearly every young man said he would not be able to bring up sexual health himself, unless he had a symptom. Some of the young men who had a family GP mentioned concerns regarding confidentiality as a barrier for discussing sexual health with a GP.

‘Well I guess because he’s sort of initiating the conversation then I wouldn’t mind talking about it with him but it just wouldn’t be something I’d bring up with him.’ (Theo, 21)

‘I think a lot of people still find it quite hard to bring up….if you don’t trust them you’re not sure how they would react.’ (James, 20)

‘There would be ways they could bring it up so it would be OK. But if it’s just randomly on the spot, you know if you’re not ready for it, then you just probably wouldn’t. You would just want to get out of there.’ (Maceij, 16)

‘I reckon if they brought it up I might. But I don’t think I could say it first…so if they brought it up first, I reckon that’d be a lot more comforting… I just don’t feel comfortable talking about it with my doctor…especially if something turns up positive, I don’t want my parents finding out. That’s probably the concern.’ (Hil, 17)

Preferred characteristics of GP when discussing sexual health

Most young men preferred to discuss sexual health with a male GP, and some expressed a preference for one that was young or middle-aged. The minority preferred a female GP. Some young men did not specify any age or gender, simply preferring the GP to be competent.

‘I mean, if there is a similar age, it would be easy and open but if you see this GP being 60 years old, you would automatically think, OK, they are people who are conservative; I shouldn’t ask about sex. We should get younger GPs to help with the young people.’ (John, 19)

‘…having someone older and unknown, particularly if it was a female doctor, could feel very uncomfortable.’ (Barry, 25)

‘It wouldn’t be to a chick doctor.’ (James, 17)

‘As long as they’re smart and know what they’re doing, I don’t really mind about the age.’ (Gap, 17)

‘I wouldn’t be able to talk to some old dude about it because that would just be creepy as.’ (James, 17)

‘I would want them to be, like young, but other than that it’s all right. Nah I wouldn’t care (male/female).’ (Luke, 17)

The views of young men on GPs and GP clinics

Many of the young men expressed a dislike for waiting at GP appointments. Some expressed a dislike for doctors who use medical jargon, and a preference for those who explained things clearly. Many young men under the age of 18 years were unaware that they could see a GP independently of their parents.

‘I don’t know, if he was not speaking all professional, like all these massive words. Speak like I suppose, to a normal person, not like you’re talking to another doctor…(I hate) just waiting and it’s just a pain in the arse.’ (James, 17)

Young men are vulnerable in regard to sexual health

The vulnerability of young men in regard to sexual health was illustrated by multiple themes: lack of knowledge about contraception and STIs, apathy towards sexual health, and immaturity in the teenage years.

Lack of information

There was a variable level of knowledge about contraception and STIs, ranging from overestimating the efficacy of condoms, to being unaware of the meaning of the term contraception. Many of the young men were reluctant to show their lack of knowledge when discussing these matters.

(re: STIs):              

‘I know heaps, but right now, I can’t think of anything.’ (Gap, 17)

Contraception

Various terms were used to describe contraceptives (Table 3). All young men were aware of condoms and most of emergency contraception (EC). Commonly, the morning-after pill was mentioned but some less orthodox EC measures were also mentioned.

(re: EC) ‘There’s something with a towel and the chick just stands up and…there’s all different ones I’ve been told about the boys have done and…’ (Jackson, 16)

Condoms

Many of the young men overestimated the efficacy of condoms and some young men said condoms were expensive.

‘Aren’t condoms 99.7% (effective) or something like that? I’m probably wrong.’ (Chris, 21)

‘I think the condom is more reliable (than the pill) I think. I’m not sure.’ (Bob, 21)

‘Condoms nowadays break. I bought a packet and I swear half of them just broke…you waste all your money on them. They cost heaps and I can’t afford to pay for them if they’re going to snap on me all the time…I would wear them but I can’t afford them.’ (Bond, 16)

Withdrawal method

Many of the younger men said use of the withdrawal method was common, especially when condoms were not available. Their knowledge of the pitfalls and drawbacks of this method was variable.

(In response to the question ‘Is withdrawal reliable?’):

‘ Yeah. It is, isn’t it?’ (Bond, 16)

‘Yeah, if they’re not wearing a condom they’ll do that (withdrawal)…yeah, they think it works.’ (Harry, 16)

‘50% of my mates don’t even use condoms…yeah they just pull out and that’s it.’ (Dobel, 16)

‘I’ve used it a few times, but still – I don’t shit bricks, obviously how many – there’s 12 that go out of a thousand sperm that get shot out of whatever, but it’s still risky.’ (Jackson, 16)

STI testing

Some of the young men were aware an STI test was usually a urine test, but many incorrectly thought it always involved a genital examination or swabs.

‘From what I’m told, you pee into a container, or something and they check that.’ (Chris, 21)

‘Oh obviously they check your whole genitalia. You have to take….pretty much….think they stick a camera up there, but I know someone, I can’t remember what it’s called though. But probably they just – they’d check it out and they do blood tests or something. I don’t know. I can’t really remember.’ (Jackson, 16)

‘I don’t even know what the test involves. I know about it, but I don’t know what you do about it.’ (Bond, 16)

‘That’s what people think it is, a swab.’ (Dobel, 16)

STI symptoms

Many of the young men were unaware that STIs could be asymptomatic and felt that a test was only required if a symptom was present. The young men did not mention long-term complications of STIs, such as infertility in women. A significant proportion of the young men catastrophised STIs to a chronic, life-long infection, illustrating that their lasting impressions were of HIV, herpes or hepatitis, rather than more common infections such as chlamydia.

‘Most people I know just say, if it looks all right, it’s fine.’ (Harry, 16)

‘It’s not something you want to have with you, because once you have it, you can’t really get rid of it.’ (James, 20)

(re: STIs) ‘A whole life sentence.’ (Dobel, 16)

Apathy

Young men were apathetic when it came to sexual health. They felt this was due to lack of information, alcohol and a general lack of concern.

‘Normally people just forget it and hope (the girls) are not ovulating.’ (John, 19)

‘I think with the use of alcohol, the worry diminishes.’ (Fernando, 22)

‘Like I don’t know if it’s like, they don’t know, or they just don’t care.’ (Luke, 17)

About sexual diseases, like a lot of kids don’t understand what they’re doing, like, they just go out and they just root anything.’ (Bob, 16)

‘Some blokes are just like, whatever.’ (regarding sexual health) (Maceij, 16)

Immaturity

Immaturity and poor decision making in the teenage years was displayed by the younger participants and reflected upon by the older participants. The quotes illustrate the sense of invincibility that many young men have and their inability to make a decision in the heat of the moment.

‘I took more risks when I was younger…you know, I didn’t think about it…it was just as, the prospect of getting one of my partners pregnant, was just still as horrifying as it is now.’ (Gavan, 23)

‘I mean because young men think they’re kind of bullet-proof and it won’t happen to them.’ (Cyprus, 20)

‘I think that when you’re younger you’re more likely to take a risk and younger guys might think that, I don’t know, it might be cool to do it without protection.’ (Theo, 21)

‘I see all this stuff and you think, I’m always wearing a condom now, but if it’s when … if it’s just in the moment, anything in the moment, in time, you don’t really think about it, you just – it’s just, when you’re sober and you’re just sitting there, you’re like, yeah, I’ll always wear one. Even when you’re not sober and it’s happening, you’re not really thinking should I, shouldn’t I, should I go it? Until after and you’re like, oh shit.’ (Bond, 16)

Discussion

This is the first Australian qualitative study to explore how young men feel about GPs introducing the topic of sexual health in an unrelated consultation, thus there is little information with which to compare the findings. While the two cohorts of young men differed in age and were interviewed by researchers of different genders, emerging themes were common between the groups. The difference in gender of the researchers may have in fact been a strength, making the common themes more certain. Other limitations include a small sample size that was within only two institutions and, to satisfy ethical requirements, that details of sexual orientation and activity were not sought. However, data saturation was reached and the participants varied in their demography.

GPs are an accessible and appropriate resource for patients in regard to sexual health care and information. The Australian Study of Health and Relationships¹⁰ found general practice was a more common source of STI information and treatment than sexual health clinics. The Secondary Students and Sexual Health Survey¹ found that GPs were the most trusted and preferred source of sexual health information for young people. Research from 1990¹¹ found that most adult men have sexual health concerns but few will bring it up with their doctor, preferring the GP to raise the topic. This study suggests that these findings are consistent with today’s young men – they desire sexual health information from their GP, but feel unable to bring it up themselves.

In 2008, Pavlin¹² found that young women did not want a sexual history taken when being offered a chlamydia-screening test; they simply wanted the test offered universally on the basis of age. This study highlights that the phrases, or segue, used by a GP can make the patient more or less comfortable when discussing sexual health. The study also suggests that young men feel it would be acceptable if sexual health was raised on the basis of age (eg: ‘the government is doing a push to offer a test to all young men your age…’). Added to this we have found that young men lack important information regarding their sexual health, for example, that STIs can be asymptomatic, the efficacy of condoms and the pitfalls of the withdrawal method.

Some GPs may feel they need a context in which to raise sexual health matters, believing that young men rely on other sources for information, and may consider questions about sexual health intrusive. However, this small qualitative study suggests that young men are happy for GPs to bring up sexual health in an unrelated consultation, provided the presenting health complaint isn’t serious, and it is done in a sensitive and appropriate manner.

When a brief intervention and/or a screening test is offered by a GP it is important to explain that STIs may be present without symptoms, and that a chlamydia test is a urine test if no symptoms are present. Female GPs should broach the topic of sexual health, but explain that the young man is welcome to follow up with themselves or a male colleague, similarly to the way in which some male GPs broach Pap smears with their female patients. Male GPs should raise the topic of sexual health wherever possible and appropriate when seeing young men.

Implications for general practice

• Sexual health should be raised by male GPs in consultations with young men whenever possible and appropriate.
• Female GPs should broach the topic and offer a test, but explain that the young man could follow up with themselves or a male colleague.
• GPs should offer sexual health education to young men rather than assess their knowledge.
• Assessing knowledge during a brief intervention may be inefficient as young men are unlikely to let on what they do and don’t know in a short amount of time.
• Sexual health can be raised using the government, age-based example, mentioning confidentiality, an STI test offered (explaining that it is just a urine test) and some brief information on contraception and STIs.

Competing interests: None.
Ethics approval: The University of Melbourne Human Research Ethics Committee. (Reference number 1238040.1)
Provenance and peer review: Not commissioned; externally peer reviewed.