Interest in men's health, including their sexual and reproductive health, has been growing over the past two decades. The 1994 International Conference on Population and Development in Cairo and the 1995 Fourth World Conference on Women in Beijing both recognized the effect of men's behavior on women's health, highlighted the importance of shared responsibility and sparked interest in developing interventions to increase male involvement in reproductive health programs.1 A 2002 report by The Alan Guttmacher Institute emphasized that the sexual and reproductive health concerns of men are important in their own right, not only because males play important roles as fathers and sexual partners.2 The National Survey of Adolescent Males, the Youth Risk Behavior Survey, and studies and reports sponsored or produced by other organizations have significantly contributed to the growing body of knowledge about men's sexual and reproductive health concerns, beliefs, attitudes and behaviors.3
Since 1997, the Office of Family Planning in the Office of Population Affairs at the Department of Health and Human Services has funded diverse community-based programs to learn how to engage with and provide reproductive health services to males.4 This special report describes sexual and reproductive health services and how they have evolved at one of those programs—the Young Men's Clinic, an ambulatory clinic for adolescent and young adult males in New York City.
THE YOUNG MEN'S CLINIC
The clinic is a component of a reproductive health program jointly operated by the Center for Community Health and Education at Columbia University's Mailman School of Public Health and NewYork-Presbyterian Hospital. It is located in the upper Manhattan community of Washington Heights, which has the highest concentration of Hispanic residents in New York City.5 Created in 1987, the Young Men's Clinic is the only facility in the city specifically tailored to address the sexual and reproductive health needs of adolescent and young adult men, and has been recognized for many years as an important model of the delivery of community-based health care services to young males.6
The Young Men's Clinic provides medical, social work, mental health and health education services at two clinic sessions each week. Services are provided in the clinical space used by the Center for Community Health and Education's reproductive health program, which serves adolescent and adult women at more than 25,000 visits each year. Between 28 and 35 men are served at each session. Use of the clinic has almost tripled since 1998: Some 1,452 men made 2,522 visits in 2002, compared with 506 men who made 908 visits in 1998.
The target age range for the clientele of the Young Men's Clinic is 13-30. Seventy-five percent of patients are 20-29, and 46% are 20-24 (the male age-group with the highest rates of gonorrhea and chlamydia7). Ninety-five percent are Hispanic (the majority of whom identify themselves as Dominican); 3% are black. Approximately half of the men are employed either full- or part-time. Only 25% of patients receive Medicaid benefits, and 3% have some form of private insurance.
The Young Men's Clinic evolved out of the adolescent family planning program that has been operated by the Center for Population and Family Health (now the Heilbrunn Department of Population and Family Health) since 1976. Both the scope and the use of services have shifted with fluctuations in funding and with increased knowledge about the needs of young men.
Use of reproductive health services by males was generally low during the 1970s (few of the male involvement demonstration projects sponsored by the Office of Population Affairs during that period attracted many males.)8However, the emergence of HIV and AIDS, concerns about rising teenage pregnancy rates, and increases in the proportion of teenage births that were nonmarital prompted renewed interest in developing strategies to reach young men during the early 1980s.
Knowledge of young men's sexual and reproductive health needs and behaviors was limited during the mid-1980s, and the available information was typically obtained from women. To increase knowledge of factors that female and male Hispanic adolescents perceived as barriers to using contraceptives and family planning clinics, researchers from the Center for Population and Family Health conducted and videotaped focus groups with youth from the community.9 Several of the male participants said they were reluctant to visit a clinic close to their homes because they did not want to be identified as sexually active ("What if my aunt sees me!"). Participants also believed that family planning clinics are for women only, and that talking about birth control is not "manly" ("Men are supposed to know these things"; "Women expect you to take charge"). Embedding sexual and reproductive health care within a broader menu of services was endorsed as one way of reducing men's embarrassment over being seen at the clinic ("If I could limp in like I hurt my ankle playing basketball, I'd tell the doctor I had a drip").
The focus groups triggered a substantial (and unexpected) level of interest among the young men. Several returned to the hospital to watch the videotaped sessions (which were followed by discussions about HIV and condoms), and suggested other recreational activities that could be taped and used to connect men to services. Videotaping was extended to include break dancing in the streets, performances at school talent shows and basketball games in local parks. These activities attracted young male performers and athletes to the hospital clinic, and most young men enthusiastically participated in discussions about HIV and sexually transmitted diseases (STDs) after viewing their videotape.
These young men also functioned as gatekeepers, linking faculty at the Center for Population and Family Health to adults at community-based organizations. As common missions, interests and needs were identified, partnerships were forged between the burgeoning "men's program" and agencies that were deeply rooted in the community. For example, leaders of community-based organizations accompanied young men from their programs to the health discussions. In return, faculty and students at the Center for Population and Family Health chaperoned dances and cosponsored basketball tournaments (purchasing T-shirts, and refereeing and videotaping games). Training in cardiopulmonary resuscitation was arranged at the hospital for a local scout troop, and the scouts reciprocated by distributing flyers about the new program throughout the community.
Building on the connections established by the focus group youth and partner organizations in the community, faculty conducted in-depth interviews with high school football coaches, Little League baseball coaches, clergy and other adult "key informants" to hear what sexual and reproductive health services young men needed and how services should be designed. The consistent message that emerged from these interviews was that young men in Washington Heights had little access to routine physical examinations that were needed for participation in school, sports and work.
Informed by these responses and encouraged by the success of the videotaping outreach initiative, the Center for Population and Family Health applied to the Office of Population Affairs in 1987 for a "special initiatives" grant and received $20,000 to expand services for young men at the family planning clinic. This supplemental funding was used to develop a Monday evening clinic session exclusively for males. Pediatrics residents provided services under the supervision of an attending physician, and faculty from the Center for Population and Family Health trained first-year medical students to provide health education. With the advent of the new evening sessions, the Young Men's Clinic shifted from a street outreach and health education program to a clinical model that was complemented by occasional outreach activities.
Current Service Model
The Young Men's Clinic currently provides a limited package of such health care services as physical examinations for school and work and treatment of sports injuries, acne and other conditions. The clinic's main focus is addressing the sexual and reproductive health needs of young men—e.g., screening and treatment of STDs, confidential HIV counseling and testing, and condom education and distribution. An attending physician, a nurse practitioner and a master's-level social worker make up the core clinical team. Family medicine resident physicians augment the medical staff during six months of the year. Medical and public health students from Columbia University provide health education services under the supervision of public health faculty. Although the majority of patients at the Young Men's Clinic speak English, 90% of the salaried clinical and support staff speak both Spanish and English.
Medical students complete psychosocial histories and provide health education at initial and annual visits. Sessions are tailored to each individual's concerns and developmental level. "Teachable moments" are maximized so that men have opportunities to discuss how to use condoms, communicate with their partner about contraception, perform testicular self-examinations and maintain a regular schedule of visits to the clinic (e.g., for regular STD screening). Young men with significant psychosocial needs (e.g., referrals for mental health or employment services) are referred to the social worker.
Public health students design health education activities that they conduct in the waiting room. Discussions focus on STDs and other health issues that concern men (e.g., hernias and stress management), as well as beliefs related to the outcomes of and widespread acceptance of such preventive health behaviors as limiting the number of sexual partners and supporting a partner's use of a contraceptive method.
To create a male-friendly environment, clinic staff show sports and entertainment videos when group activities are not being conducted, and distribute magazines such as Sports Illustrated and Men's Health. Paintings of men engaged in health-promoting behaviors (e.g., holding a baby) are placed in strategic locations throughout the clinic, and photographs of distinguished men of color (e.g., Secretary of State Colin Powell and former Surgeon General David Satcher) are displayed on the clinic's Wall of Fame.
The social worker provides mental health and social services during clinic sessions and short-term case management services throughout the week. Some of these services do not require young men to revisit the clinic. For example, the social worker provided more than 800 telephone consultations in 2002. Consultations typically are brief (10 minutes or less) and focus on health education (e.g., symptoms of herpes), decision-making (e.g., how to help a girlfriend decide on a contraceptive method), interpersonal skills (e.g., how to talk to a partner about getting tested for STDs) and finding necessary services at other agencies (e.g., support groups for gay adolescents). Even though telephone counseling is not a reimbursable service, logs capture the full range and volume of this important activity, and summary statistics are reported to funders.
The increasing number of clients visiting the Young Men's Clinic challenges the notion that men are hard to reach and demonstrates that young men will engage in programs that are accessible, affordable, culturally sensitive, rooted in the community and tailored to their needs. The following outreach interventions were designed to ensure that the clinic has high visibility in the community:
• A social marketing cartoon series that portrays men as competent, caring and involved in health-promoting activities has been developed. Cartoons are printed in English and Spanish on brightly colored cards and distributed through several channels. Story lines address emergency contraception, urine-based chlamydia screening, male support for female contraceptive use, hernia, and referral services at the Young Men's Clinic. A cartoon about dual protection against pregnancy and STDs is being developed. Information about the clinic (location, days and hours of operation, and telephone number) is embedded in each script.
• Medical and public health students are sent to community events such as evening basketball games. Wearing colorful clinic T-shirts, students distribute cartoons and engage men in "life space interviews" about clinic services.
• The results of formative research at the clinic in 2001 suggested that young men delay seeking health care because they fear hearing bad news. In addition, concerns were frequently expressed about the confidentiality of test results and about pain associated with laboratory tests (especially penile probes). A seven-minute digital video about urine-based screening was produced to address these concerns. In the video, satisfied patients give "testimonials" about the clinic and describe the benefits of being tested ("I sleep better at night knowing everything is all right"). The clinic's attractive facility is shown while merengue music plays in the background. Copies of the video are distributed to community-based organizations and downloaded onto computers at school-based clinics run by the Center for Community Health and Education.
• The social worker leads discussions in the family planning clinic to help women link their partners to the Young Men's Clinic. Cartoons are distributed and discussed, and women are encouraged to make appointments for their partners. After these groups were instituted, the proportion of new male patients who were referred by family planning patients increased sharply, from 25% in 1999 to 53% in 2001.
• Although most residents of Washington Heights have limited financial resources, close family and friendship networks provide invaluable support. These networks also create entry points for introducing information about men's sexual and reproductive health services. A standard talking point during waiting room groups, for example, focuses on what men can do to take care of their sexual and reproductive health, their partner's health and the health of their children. Telling friends about the clinic is proposed as one possible action. Tapping into these networks appears to be an effective strategy: Some 25% of the men who came to the Young Men's Clinic for the first time in 2001 said they had heard about the clinic from another patient; in addition, almost two-thirds of the men who made revisits in 2000 and 2001 reported that they had told another man about the clinic since their last visit.
The Young Men's Clinic has been supported over the years by a patchwork of funding that has included in-kind institutional contributions (e.g., the clinic facility, volunteer students and Columbia faculty), private foundation and state grants, patient fees and third-party Medicaid reimbursement. The clinic has never received funds from either NewYork-Presbyterian Hospital or Columbia University.
Administrators from the Center for Community Health and Education strongly believe that to prevent transmission of STDs in women and reduce the incidence of unintended pregnancy, men must be included in reproductive health services. Since 1987, when medical services for young men were introduced, some funds from the family planning operating budget have been committed to cover medical, social work and support staff at the Young Men's Clinic.
Title X funding specifically designated for men's services was first received in 1998, when the clinic was designated as an Office of Population Affairs male demonstration project. The Young Men's Clinic received funding from the New York Community Trust that same year. These additional funds enabled the clinic to hire a part-time medical director and a full-time social worker, and to expand to two sessions each week. But although these funds provided a more secure financial base, they did not cover the total cost of operating the clinic.
The total annual operating expenses for the Young Men's Clinic are approximately $311,000, excluding administrative overhead and indirect expenses, such as rent for the clinic facility. Of that amount, $150,000 comes from the Office of Population Affairs through the New York State Department of Health, and approximately $88,000 from Medicaid billing and out-of-pocket patient fees. Other grants and funding sources provide $73,000. Uninsured patients who are 19 or older pay a nominal fee based on income, pursuant to Title X guidelines. A new Medicaid entitlement benefit that covers family planning and reproductive health care services for men and women with incomes less than 200% of the federal poverty level (Family Planning Benefit Program) has been in place in New York State since October 2002.
The Young Men's Clinic attempts to empower men to adopt and sustain behaviors that improve their health and the health of their partners. This is challenging because many of the clinic's patients, like other low-income young men of color, experience environmental and structural barriers to meeting their most basic needs on a daily basis. Many are recent immigrants, and few have jobs that provide a living wage or employer-sponsored health insurance. Shifting eligibility requirements for Medicaid coverage since the institution of welfare reform in 1996 have left many confused, fearful and distrustful of medical and other service providers.10
To improve staff members' ability to increase young men's self-efficacy and engage them as partners in their own health care, the clinic trains them to help young men identify and use personal and environmental resources to make changes in their lives (e.g., initiating condom use); avoid responding to patients in a manner that sounds blaming, threatening or minimizing and that diminishes men's motivation to take action; and communicate confidence that men can change their behavior and affect their environment. For example, when completing a psychosocial history with an adult who has never finished high school, staff are trained to ask "How did you decide to leave school before you graduated?" rather than "Why did you drop out?" When providing health education about genital warts, staff help young men save face by telling them "It's okay; many men haven't heard about viruses like this one" instead of "You should know about this by now; it's a common infection."
Parents, teachers and health care providers regularly miss opportunities to talk with young men about sexual health concerns and fail to provide them with the knowledge and skills they need to protect themselves.11 As a result, many young men are uninformed about sexual and reproductive health, unfamiliar with the health care system, uncomfortable talking with physicians and reluctant to seek help even when they have symptoms.12 A visit to the Young Men's Clinic may present one of the few opportunities men have to discuss sexual and reproductive health.
The clinic maximizes teachable moments so that young men have multiple opportunities to ask questions, obtain information, learn skills and think about their behaviors. Graduate students leading group activities in the waiting room focus conversations on factors that are associated with using condoms and with partner communication (e.g., concerns that condoms will affect sexual pleasure). Students inject these issues into discussions so they can be explicitly explored (e.g., asking whether women always feel insulted if a man wants to use a condom).
Downtime in the waiting room is also used to inform men about cancers of the male reproductive tract, describe how the testicles are examined during a comprehensive physical, demonstrate testicular self-examinations and provide guidance about what to do if symptoms are observed (i.e., call the clinic). Encouraging men to perform testicular self-examinations and to use the Young Men's Clinic as their medical home raises men's awareness of their reproductive health, establishes a baseline of what is normal and creates opportunities for expressing concerns that may warrant attention (e.g., symptoms of herpes or genital warts).
Healthy People 2010 states that developing community partnerships is one of the most effective ways to improve the health of communities.13 The Young Men's Clinic collaborates with several governmental, nonprofit and community-based organizations to leverage resources and create a comprehensive package of services. A linkage with the New York City Department of Health, for example, allows the clinic to offer urine-based screening for chlamydia and gonorrhea to every patient at no cost to the clinic. (The prevalence of chlamydia among clinic clients was about 11% in 2002. All of the men who tested positive were successfully treated with a single dose of azythromycin.)
EngenderHealth, an organization that provides technical assistance related to reproductive health throughout the world, funded the clinic's social marketing cartoons. Family medicine residents have increased the number of in-kind medical providers and facilitated referrals to the family medicine outpatient clinic when diabetes and other chronic conditions are diagnosed. A Harlem Health Promotion Center health educator is assigned to the Young Men's Clinic and provides smoking cessation services during clinic sessions.
CHALLENGES AND RESPONSES
Although the substantial increase in clinic use since 1998 is encouraging and provides evidence that men are willing to participate in sexual and reproductive health care, the success of the Young Men's Clinic has created some of its most vexing problems. Marketing activities and informal word-of-mouth outreach by satisfied male and female users of the family planning and reproductive health programs run by the Center for Community Health and Education have dramatically increased the clinic's visibility, but the growing demand for services is outpacing the clinic's capacity. Some 5-10 nonemergency walk-in patients have to be turned away and rescheduled at every clinic session. Although the clinic has adapted by collaborating with government and community-based agencies, enlisting graduate students to provide health education services, maximizing recovery of reimbursable revenue and seeking additional sources of funding, the financial challenges facing the clinic are formidable.
The Young Men's Clinic serves men who are the least likely to be insured and the most likely to be disconnected from health care. Men in their 20s are too old for the State Children's Health Insurance Program (SCHIP) and are rarely eligible for Medicaid. Moreover, many of the clinical, counseling and health education services men need are not reimbursable.14
The clinic also serves a large number of immigrants, both legal and undocumented. New York State court decisions have restored full Medicaid eligibility to legal immigrants who were eligible for Medicaid before the state implemented federal welfare reforms, but undocumented adults still do not qualify for coverage except for prenatal and emergency services.15 The policy at programs of the Center for Community Health and Education, including the Young Men's Clinic, is that no one is denied services because of inability to pay. This includes undocumented immigrants. The clinic administration and staff believe that any other position would be unethical. Moreover, health care costs would ultimately be driven up if men had to be treated at emergency rooms and their partners had to be hospitalized with pelvic inflammatory disease and other complications of untreated chlamydial infections.
As at most male involvement programs in the United States, especially those serving low-income, uninsured, minority communities, securing adequate and stable funding to provide and (given the high level of interest and need) expand services has been the most pressing dilemma. Few funding sources target men's sexual and reproductive health.16 The decision to allocate scarce resources to men's services is difficult for managers of Title X-funded programs because of the rising costs of providing services and inadequate Medicaid reimbursement rates. Moreover, despite Title X's extraordinary success in helping to prevent millions of unintended pregnancies over the last 30 years, funding for the program has not kept pace with inflation. The growing federal budget deficit and pressures on states to balance budgets have created even greater financial uncertainties.17
Limited funding in the face of the high demand for services has constrained the capacity of the Young Men's Clinic to implement several important activities, including the expansion of health education services at community venues. During the summer of 2003, however, the clinic applied for funding to launch a community-based health education and condom distribution intervention at 14 community-based organizations in Washington Heights and neighboring Harlem, and for an additional medical provider to serve newly recruited patients. If this intervention is funded, a health educator will deliver a three-session group curriculum that uses the social marketing cartoons and digital video. A slide program that walks men through a typical clinic visit by showing digital photos of staff (e.g., receptionists), space (e.g., the lab) and activities (e.g., taking blood pressure) will also be used. Men will be encouraged to visit the clinic for STD screening. Building on the success of the In Your Face school-based intervention, developed by the Center for Community Health and Education,18 the health educator will escort each young man who visits the Young Men's Clinic through his initial visit.
Although formative evaluations have informed the development of culturally sensitive outreach interventions such as the video and cartoons, and process evaluations (e.g., patient flow analyses, chart reviews and patient satisfaction surveys) have identified service delivery problems so that corrective action could be taken, funding constraints have limited the clinic's ability to conduct rigorous outcome evaluations. The clinic is currently seeking funding to support systematic evaluations of clinic interventions (e.g., the effectiveness of waiting room group activities on knowledge, beliefs and behaviors), as well as outcome studies that measure changes in condom use and partner communication among clinic users.
The sexual behavior of adolescent males has changed for the better in recent years.19 Nevertheless, more progress is needed to achieve not only the Healthy People 2010 goal of eliminating health disparities, but also increased condom use among adolescents who are sexually active, and lower rates of pregnancy and chlamydial infection.20 It is particularly important to increase primary and secondary prevention efforts that target men in their early 20s, who are more likely than younger males to engage in risky sexual behaviors and to have adverse reproductive health outcomes.21 Achieving reductions in sexual risk-taking among men in their early 20s similar to those observed among adolescent males could contribute to further declines in unintended pregnancy and STD rates among young women.
The Young Men's Clinic is successfully engaging young men of color who are poorly served by the U.S. health care system. To improve young men's access to comprehensive and integrated sexual and reproductive health care throughout the country, health organizations and community-based agencies will increasingly need to pool resources, strengthen linkages and craft strategies for incorporating sexual and reproductive health into services. Most important, public and private funding specifically earmarked for men's services must be increased.