Working With Young Men in Sexual Health Settings 2

Young men are reluctant users of sexual health and contraceptive services, particularly for preventive reasons. If young men have symptoms of a STI then they will probably end up at a GUM service eventually but it is important for all services to send out positive signals to young men so that they attend our services earlier.

In order to offer a service that is relevant to the needs of young men we need to actually deliver what men want and need.

Where possible we should buy condoms from a brand, which are advertised and can be bought in shops. Although in clinical terms there may be no difference between condoms it makes a huge difference for two reasons

  1. Trust. If we want young men to change behaviours and use condoms every time then they need to trust the product.
  2. In order to get young men into our clinics in the first place we need to show that we value them. If we give a young man 10 condoms, that could be bought in shops, they feel like we are giving them £6.

Additionally the popular condoms have more bells and whistles that make them more attractive to young men. As well as the variation in size etc (see below) the popular brands are ‘easy on’ or have odour masking to prevent them from smelling like condoms. We may think that these are unnecessary gimmicks but they have a cumulative affect in making young men believe that using condoms are easy, more beneficial and feel just as good (maybe even better) as not using them at all.

The popular brands may cost two or three pence more per condom (though you should speak to your local sales rep, because they often provide great discounts) but it is much more likely that they will be accessed and used confidently. Our clients would prefer 15 popular condoms than 20 (or even 30) unpopular ones.

How much information do we give to young men about the condoms we give them? It is important that once we have the young men in the clinic that we ‘sell’ the condoms that we are giving to them, even if they aren’t available in shops or have ‘bells and whistles’ (see below).

For example “These condoms have a flared shape at the end making them easier to get on and more comfortable. They also act as a second foreskin because the glans (bell end) moves around inside the condom during sex which can feel very pleasurable”.

Or “these are tight fitting condoms which can help you stay harder and last longer as they restrict the blood flow”, which is always better than saying “these are small size”.

Reading the literature that comes with the box can tell us more about each condom we are offering. The condom manufacturers are selling the condoms to us so we should be selling the condoms to our clients. So looking at your condom stock; how wide are they? do they have an odour mask? are they straight sided or flared or contoured? how long are they? do they have lots of lubricant on or ‘gentle’ lubricant (not as much)? how thick are they?

Most condom companies have a range of publicity leaflets about their condoms; for example Durex have leaflets about how their condoms are tested. Get hold of these and read them, and make them available to clients. If you demonstrate to male clients that you know about the condoms that you are giving to them, then it demonstrates that you value the client, making it more likely that they will value your service.

Or you can read my post about condom types here

We know that a broad range of condoms impresses men. Young women are able to access many different forms of contraception and are often given the choice of many different brands. Having different types of condoms is a common factor for projects that attract more young men. It shows that we value them and also demonstrates that we know that young men would like a choice.

Condoms of different sizes and shapes are important so that clients can find the right fit for them. A recent study suggests that incorrectly fitting condoms can have an effect on slippage, breakage, erections and pleasure. The abstract is here and a really interesting podcast about it is here. Most companies offer a flared, straight fitting and narrow ‘trim’ size condom as well as those with a range of thicknesses. Flavoured condoms decrease the risks associated with oral sex, which young men are increasingly concerned about, and also demonstrate the condom use can be fun.

There are also condoms that increase pleasure with ribs, studs and even spiralled contours. Some such as the Durex Performa can delay ejaculation and others can make people ‘tingle’. These may be gimmicks and may not have a huge physical effect but that isn’t the point. They work because they encourage people who wouldn’t normally wear condoms to have a go because they associate sexual pleasure and success with the products. (Although for male clients new to sex, or having sex with new partners, I would always advise using the most regular condoms at first.)

Lubricant is also important because some clients enjoy having anal sex and they can also help make vaginal sex and mutual and solo masturbation more pleasurable – many younger clients refer to this as ‘bashing cream’ and can help many boys with tight or no foreskin. Additionally informing clients of the benefits of putting a very small dab of lube on the end of the penis before putting the condom on is a good idea, so long as they are also told about making sure the condoms don’t slip off.

Once we have a variety of condoms it’s important to offer a choice of condoms rather than a mixed bag, which they could take very quickly. This might seem obvious but spending a little more time with clients to get them to choose the condoms means that we have more opportunity to establish a dialogue and a relationship with them so that they feel more comfortable asking questions and also that they feel more comfortable receiving relevant information.

It is essential to build working relationships with young men in order that they ask questions about their own problems or find out more about sexual health generally. Young men invariably do not really begin to trust our services until they have visited at least a couple of times.

Young men have low levels of knowledge around sexual health and have few safe opportunities to explore their feelings about relationships and sexuality. Parents are often reluctant to talk to their sons about sex (particularly dads) and schools often are unable to offer more than very basic biologically focussed SRE.

Young men are very good at pretending to know something when they don’t and if they are not feeling comfortable enough in our services then they will do everything they can to prove that they know everything about sex, and that maybe they could teach us something about it (and maybe they can!). This might lead us to believe that young men don’t want to have these opportunities to learn and thus we do not need to waste our time thinking about how to offer this.

However sexual health services which are geared up to work with young men give them a great deal of information and advice, simply because they are not getting it from anywhere else, and also because they have created the right environment and used the right language to make this ok. For example it is always good practice to demonstrate condom use for first time clients, even if the client is sure that they know how to use them. I do this by saying that I have to do this because it’s part of the policy and by being very matter of fact about it.

In my opinion many Condom Distribution Schemes do not really meet the needs of young men if they do not offer this opportunity for them to ask questions and to learn more. Just giving young men condoms may meet their expressed needs but it doesn’t meet their unexpressed needs that may be found in the ‘jam’ of the donut.

When we first see first time clients there is a lot to get through. It can be overwhelming for the client if we try to give them all of the information that we think they will need because we are not sure if we will ever see them again – as well as trying to establish Fraser competency and whether they are sexually active. We need to achieve the right balance between giving enough information to clients without damaging the voluntary relationship they have with us.

The key is to say as little as possible in each visit, to pare down any information to the very basics and to offer this information verbally and in written bite size chunks. If we try to cover condoms, STIs, relationships, the law, consent, non-penetrative sex, testicular cancer, puberty, genital health and sexual anatomy in one visit;

  • Our clients are unlikely to take everything in
  • They won’t get chance to speak or ask their own questions

We need to be confident that our clients will come back (usually with their friends). To enable this to happen in my services I give out smaller amounts of condoms and encourage clients to return, often increasing the number of condoms once they have attended a few times.

If we are giving out condoms for the first time we need to ensure that our clients can use them properly and that they know what to do if it goes wrong.

A typical first time visit to my service might include the following

  1. Introduction to the service, my name, what we offer.
  2. Confidentiality and what this means (see below)
  3. Registration
  4. The condoms and a brief description as I put a selection of each different kind into their bag
  5. Handing condoms over with an instruction leaflet and a leaflet about the different condoms (in a bag closed with a sticker).
  6. Demonstration of using condoms “I do this with all clients for the first time – it doesn’t take long” including information about emergency contraception
  7. Any questions? (there are often questions)
  8. Remember that just because you have condoms doesn’t mean you have to have sex (if not sexually active).
  9. Have you considered talking to your parents about coming here? (if under 16)
  10. Where and when the next clinic is for them to get more.

Even this is quite a lot so I always explain that for their next visit they can choose their condoms and go (though in reality that doesn’t usually happen).

For follow-up visits, if clients do not ask questions an issue is raised by either asking open questions or by giving them a written piece of information.

Information needs to be given both verbally and written down as this has the greatest impact on client knowledge levels. Having written information also means that we can be more succinct verbally. It also means that for occasions when clients aren’t feeling comfortable chatting we can pop a leaflet into a condoms bag with a quick description of what it is. For example ‘this is a leaflet about how you can check your testicles for cancer, it’s important that you check them once a month, if you have any questions come back and see us’.

The Bite Size SRE leaflets have been developed, by me, over 10 years of working with young men in sexual health projects. They are a way of delivering an informal programme of SRE to young men and they also help to answer the most commonly asked questions. They really do work and young men are often disappointed when I have run out of leaflets!

Once the relationships with clients begins to build over a couple of visits clients then ask questions specific to their own problems or sex lives.

Much of this resource is about establishing a preventative model of sexual health for young men. This would encourage young men to come in sooner, preferably before they start having sex or before they start having unsafe sex.

I currently run this kind of project alongside a GUM clinic and it acts as a referral pathway for many young men that wouldn’t usually have accessed a service or would only have accessed a service when they were desperate (when they were symptomatic or given a PN slip). They get check-ups while they are there because they are easy (they are already in the building), because they think it’s a useful service, with lovely staff and also because we have addressed their fears.

When young people attend a sexual health service for the first time, it is probably the first time they have ever attending any health service without a parent before. We need to remember that this is a big deal for them, even when they are macho, swaggering, be-hooded young men! There are a number of things that services can do to give clients more confidence in this area. They could produce a welcome leaflet or poster which explains what happens and who does what. They can also be told that all the tests will be explained to them by the practitioner and that they can refuse any test.

Young men worry about confidentiality in the same way that all young people worry about confidentiality, just because they may not seem worried about it doesn’t mean they aren’t. The ‘You’re Welcome’ guidance has a section on this. Reminding young men through the publicity, through posters, through welcome leaflets and verbally can help them to feel more at ease about their security.

Young men have deep-seated anxieties about whether a swab will be taken from their urethra. It is very important to address this with clients, whether you do this or not, at the earliest opportunity: preferably in the promotional materials for the clinic. Services offering pee in a pot or self swabbing or rapid HIV testing should be very upfront about this. If a service does take swabs, for instance for symptomatic GC, then they should say what it involves and should explain how uncomfortable it may feel.

Also many young men feel very uncomfortable at the idea of having a male practitioner examining them (in fact some young men prefer female workers generally, even those delivering non-clinical services). We might perceive this as a trivial concern, and perhaps even homophobic, but I think that it’s an important fear which needs to be taken seriously. I’ve spoken to young men who have happily been examined by male and female doctors. In fact young men have reported to me that, in the days of urethral swabs, the male doctors were much more gentle! If they feel assured that they are in capable hands and they know what is happening before it happens then they feel much more comfortable.

Young men do not want to be in a clinical setting for a long time; so it makes sense to try to speed up how long it takes to see them. However we need to ensure that we are still able to offer a thorough service. Seeing young men quickly is not the answer in itself; they deserve a high quality thorough service too, we just need to be able to deliver it in a way that can meet their needs.

Many Condom Distribution Schemes sacrifice the amount of time that a young male client can spend with a sexual health professional, in order that they get their condoms quickly. In my experience most young men are desperate to access the correct information and advice once they have built a relationship with the service; this takes some time to do in order to build trusting relationships.

Furthermore it is tempting to make sexual health screening easier and quicker in order to make it easier for the client; however, a thorough examination can reveal many more issues and problems. Often clients believe that they are asymptomatic when they are not, for example, or; young men may not be aware of other penis related conditions such as phimosis or balanitis. If young men have taken the time to wait for a service then they feel good in the knowledge that they are getting the 5* treatment, the full works, a proper MOT!

Again this is something which, in my view, is a weakness of many Chlamydia Screening Programmes, particularly those which do not work in close partnership with local sexual health services. We may think that this ‘arms length’ service is something which young men want, but if we only work with young men on an external and superficial level then we are not working with them around issues which are truly going to improve their sexual health and that of their partners.

Part Three

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