“I’ll look it up on the Web first”: Barriers and overcoming barriers to consult for sexual dysfunction among young men

Questions under study: Our aim was to identify the barriers young men face to consult a health professional when they encounter sexual dysfunctions and where they turn to, if so, for answers. Methods:We conducted an exploratory qualitative research including 12 young men aged 16– 20 years old seen in two focus groups. Discussions were triggered through vignettes about sexual dysfunction. Results:Young men preferred not to talk about sexual dysfunction problems with anyone and to solve them alone as it is considered an intimate and embarrassing subject which can negatively impact their masculinity. Confidentiality appeared to be the most important criterion in disclosing an intimate subject to a health professional. Participants raised the problem of males’ accessibility to services and lack of reason to consult.Two criteria to address the problem were if it was long-lasting or considered as physical. The Internet was unanimously considered as an initial solution to solve a problem,which could guide them to a face-to-face consultation if necessary. Conclusions: Results suggest that Internetbased tools should be developed to become an easy access door to sexual health services for young men.Wherever they consult and for whatever problem, sexual health must be on the agenda.


Introduction
Literature on adolescent sexuality disproportionately concerns young women [1, 2].Ye t, young men often have very different needs [3] and there is little data on male adolescent needs, in terms of sexual and reproductive health.
While young women generally consult for contraception or gynecological screening, young men are virtually absent from any type of facility that treats sexual and reproductive health [4].Although these facilities are open to them, young men use them rarely because of the stereotypical idea that they are intended for women [5,6].
Evidence indicates that male adolescents are often confronted with barriers which prevent their access to sexual health services.A qualitative study conducted in the US [7] suggested internal barriers such as fear of stigmatisation and loss of social status, shame, embarrassment; and external barriers including lack of respect from health professionals, lack of confidentiality or intimacy,a nd problems accessing the health care system.
Nonetheless, young men do have questions about their sexuality.The evaluation of a Swiss in-formation Web site for adolescents (www.ciao.ch)[8] indicated that almost half (47%) of the questions asked by young men concerned the subject of sexuality and the questions were, proportionally,the most frequent (46%) among 16-18 yearolds.Similarly,aSwiss survey [9] showed that 7% of male and female adolescents reported having a need for professional help concerning problems linked to sexuality and contraception.However, while one quarter of the young women consulted a professional to solve their problem, only 4% of young men did.
As aresult, there seems to be adiscrepancy between what young men need and what they search for and/or obtain [10].Problems linked to male sexuality in general and sexual dysfunction (SD) in particular are often taboo issues among young men, even if they can be relatively frequent and a cause of stress given the level of intimacy of the matter.However,the question regarding whether young men try to find solutions and, if so, where they find them, remains unanswered.
While previous research has shown which barriers prevent young men from consulting specialised sexual andreproductive services, none-to our knowledge -has explored which barriers prevent young men from consulting health professionals of any type for SD problems.The purpose of this exploratory study was to identify precisely which barriers adolescent males (aged 16 to 20 years, living in Switzerland) face in addressing a health professional (HP) when they encounter SD problems or questions and where they turn to, if so, for answers.

Methods
We chose to conduct a qualitative research in order to acquire precise accounts and in-depth descriptions from adolescent males themselves [11] and to understand the behaviors and attitudes of this particular group [12].A focus group (FG) setting was chosen as group interviewing was previously shown to be an effective and efficient method in accessing adolescent cultures particularly around sensitive issues [13] such as sexuality [14,15].It can facilitate the discussion of taboo topics because less inhibited members of the group break the ice for shyer participants [16].Moreover,F Gs offer the advantage of the interaction amongst participants as they query and explain themselves to each other,which offers valuable data through consensus and diversity [15][16][17].

Participants
The main author conducted 2 FGs with a total of 12 young men in May and June 2008 (mean age of the sample 17.2 years).This study was intended to be a pilot for future larger research.
Recruitment criteria were being aged 16 to 20 years and fluent in French.Since our research group works closely with ahealthcare unitfor adolescents, recruitment began there with 3 participants for the first FG (17,18 and 20 year-olds), and two others (18 year-olds) were brought in using a snowball method.The second group of 7 young men was recruited in a public high school, including students from two different classes, 5 first-year (16year-olds) and 2second-year students (17 and 18 yearolds).

Procedures
The first author was the moderator for both FGs.Each FG lasted about 2 hours and was audio-recorded.
During the FGs, discussions were triggered through the presentation of 4 vignettes, which corresponded to questions posted by young men and women aged 17 to 20 years on www.ciao.ch between January and April 2008.This Web site is designed for young people and focuses mainly on health issues [18].
The vignettes chosen for the FGs concerned premature ejaculation (PE), lack of ejaculation, or erectile dysfunction (table 1).Using scenarios allowed participants to talk in a hypothetical manner about what they would do if they were in place of the person asking the question.It avoided having to talk about their own experience, which could be a source of embarrassment.Based on these, participants were asked the following main question: Who do young men contact and where do they turn to for answers in the event of such a problem?
The study was approved by the University of Lausanne's Ethics Committee and the participants signed a consent form at the beginning of the FG.To compensate for their participation, young men received a cinema ticket.

Data analysis
The recordings were anonymously transcribed verbatim.Narrative analysis was conducted basedo na grounded theory process in order to create explanatory schemes based on the experiences of those involved with the subject of interest [12,19].Tr anscripts were coded looking for predominant and relevant themes.Codes and themes were discussed by all the authors until a consensus was reached.The codes were then synthesised, classified and analysed in order to answer the predefined research question.Citations used in this text were translated into English by the main author.

Ta ble 1
Four scenarios presented to the focus group participants.

N°SexA ge Scenarios
1M ale 20 "For the last few days, when I make love to my girlfriend, I have a hard time getting an erection (it remains quite soft).What can I do to change this?" 2M ale 17 "I've been going out with my first girlfriend for 5 months and we've already had sexual intercourse about 10 times.Each time we do, it lasts very little time because I ejaculate very rapidly.My girlfriend is very understanding, luckily, but I'm wondering why this happens to me?" 3F emale 20 "I've been going out with my boyfriend for 2 years.At the beginning, sexually, everything went very well.For about 2 months, each time we make love, my boyfriend doesn't finish up; he doesn't ejaculate.I asked him if it was my fault, he said no, and that he still feels desire but that it's because of the medication he is taking (he takes antidepressant medication).Is it possible?For me, sex is very important in a relationship and I'm worried.What are the reasons for why a man cannot ejaculate?"4F emale 17 "I would like to know what to do so that my boyfriend has an erection more often, because sometimes when we make love, his penis doesn't have an erection anymore." Note: vignettes were taken from www.ciao.ch between January and April 2008.
After analysis, different themes emerged as barriers to consult for SDs and the Internet appeared as a solution to overcome them.

An intimate and embarrassing subject
Participants first suggested that these were not the type of problems that they talked about with anyone at all.They preferred trying to solve them alone.The young men considered sexuality an intimate subject: "I've never had a friend who told me about his sexual life in detail.And at the same time, […] I don't want to hear about it", and deemed this type of information personal, therefore "I would be ill at ease talking about it in front of someone." Fear that perceptions of their masculinity may be negatively impacted appeared with the idea of disclosing SD issues to anyone.For the young men, masculine pride was involved in SD and therefore raised shame and uneasiness, especially as society puts a lot of pressure on "male performance".Moreover,participants claimed that young women had a greater habit, ability and courage to talk about their problems and personal affairs, contrary to young men who were more often ashamed and embarrassed by problems linked to sexuality: "Already,p ride, I think they [young women] show it probably less … Well, the dominant male, ideals and all that … They [young women] feel more ready to talk about their problems and to share them."Thus,they declared that they had more difficulty setting pride aside and admitting that they had a problem for which they needed help.
Masculine pride, shame and embarrassment were also raised in two disclosing situations.Firstly,p articipants did not feel comfortable approaching a family planning center,a s they believed it included mainly reproductive issues which were considered as females' responsibility, while young men were more preoccupied with sexual performance.In this perspective, they declared that the expression 'family planning' entailed a long-term vision that did not correspond to their priorities: "I don't understand why it's called 'family planning', I mean, yeah I do, in the long term, but it's almost scary …".Secondly, shame was raised with the option of consulting a GP in a private practice: "It's embarrassing because we still have a person in front of us, so it is still a part of oneself that we are revealing."

Confidentiality and roles
Confidentiality appeared within the two groups as av ery important criterion in disclosing such an intimate subject as sexuality; in particular when addressing HPs and family planning centres.In the case of HPs, participants pointed out that lack of confidentiality was amajor barrier to consult.In particular,t hey considered it difficult to consult without telling their parents as the bill is sent home.The question of whose role it was to take care of SD issues also came up in the case of a family planning centre.Participants considered it, theoretically,asthe most appropriate place to talk about sexual issues as it gathers professionals who are used to taking care of sexual problems, and who are specialised and competent on this topic.

Lackofaccessibility and of areason to consult
Concerning the general idea of consulting a HP,participants raised the problem of not knowing whom to address, where to consult, where to find services, and how to make an appointment for this type of problem.Nonetheless, the neutral status and the nonjudgmental character of a doctor was presented as a positive point: "Talking to a professional is better than peers because [of] the status of being a doctor […] and going home in the evening and not thinking about what patients told him." While it was considered easy for young women who can go and see a gynecologist, young men faced two major problems.The first one was a lack of a reason to consult, which young women have with contraception: "Women, they go already at the beginning without there necessarily being aproblem."Incontrast,young males are not followed on a regular basis.Thus for a young man to go to a family planning centre means that there really is a problem: "When you go, that means something is really going wrong."T he second problem was a lack of habit to consult as it is not part of the norm to discuss these types of issues, nor is it part of their reflex to think about consulting: "If boys have a problem, they don't think immediately of going to afamily planning centre, because to start with, they don't have much reason to go there".
As an excuse to consult and a way to counter these gender differences in consultation habits, some participants suggested that all teenage males have a mandatory health visit.This could be an incentive for future consultations and a way for it to become slowly part of the norm.

Along-lasting and asomatic problem
Overall, whether or not this type of problem deserved to be disclosed depended on whether it was long-lasting or recurring or just a phase, or whether it was considered physical or psychological.If the problem does not last (generally defined as up to one month), it is better to try to solve it alone.For example, they believed that it could be a question of stress and pressure, in which case there is not much to do but try to work it out alone.However,if the problem keeps up and occurs repetitively,then one should start taking action: "Afterwards, if it happens repeatedly and the guy doesn't know why,i t could also be another problem."

Results
Ag eneral tendency emerged from young men's discourse to distinguish between two forms of problems and ways of treating them.Psychological problems are one's own responsibility and therefore should be taken care of alone: "[…] it could also be completely psychological if they are stressed […], it's normal that there's a dysfunction like that."Whereas in the case of a physical problem, it becomes worthwhile consulting: "I think that if we are sure that it's physical, there is inevitably a moment when we'll have to talk about it with a doctor or someone, so it doesn't get worse."In this perspective, participants mentioned that the role of a GP is to take care of somatic problems but not of sexual problems.

The Internet as an initial step
The Internet was brought up by all participants as a very useful tool when confronted with SDs and as an initial solution to most of the mentioned barriers.It was judged to be the best way to deal with these types of problems, with many advantages compared to any other offline consultation form (table 2): (a) maintaining intimacy; (b) preserving anonymity ("by using a pseudo"); (c) protecting one's pride; (d) giving the feeling of freedom; (e) providing information at no cost; (f) avoiding face-to-face confrontation; (g) accessing online consultations; (h) having direct access to information at any time.
Three different ways of using the Internet were developed.Firstly,t he Internet is a way of finding information about any subject rapidly through research engines: "Simply,just to find information, it's fast … Then, asking a question, I don't even know if I would do that, because you can easily find 45 page files on all kinds of problems you can have …".Secondly,participants pre-sented the Internet as a place where they can address other people for questions or learn about similar experiences by posting questions on blogs, which aparticipant mentioned concerning PE: "In my opinion, there are many blogs where one can talk about it I think."Thethird way of using the Internet in this context is by putting up questions on specialised Web sites where trustworthy professionals answer: "One can trust the Web site if there arespecialistsanswering".Someparticipants mentioned that one should be cautious about obtaining answers from just any Website, and should pay attention to whether it is official.
From this perspective, participants suggested the strategy of having an initial contact on the Internet as a first step to solve a problem which could then guide them to a face-to-face consultation if necessary.It provides an opportunity for a first definition of a problem, helps the person decide whether it is worth consulting and find out where to consult according to the problem: "Between those who have a real problem, those who don't, those who need to go to the family planning centre or to the doctor,at least it makes it possible to sort it out before hand."Forthat matter,participants suggested that the appointment could be taken directly online: "Using that you don't need to explain too much orally either."Therefore, searching the Internet can help define if aproblem is serious and if it is necessary to be followed by a visit to the doctor: "If, for example, I search on the Internet and I see that it is not bad, I'm not going to go and see a doctor just for the fun of it; if I see I need to, then I'll go …".
Finally,i t was noted that more information should be given regarding where to find answers on reliable Web sites.f) Avoiding face-to-face confrontation "I would be ill at ease to talk about it in front of a person.I don't think I would manage.On the Internet, it's easy; you are in front of a screen, you write, and you come back in two days to see if there is an answer."g) Accessing online consultations "If we have professionals who are as competent on the Internet as at the family planning centre, we might as well go on the Internet so that we don't need to confront them and go anywhere."h) Having direct access to information at any time "It is the direct access because it's true that on the Internet, we search on Google and we have a direct access at any time, whenever we want."

Ta ble 2
Advantages of the Internet compared to anyother offline consultation form and example quotes from the participants.
This study presents two important issues.Firstly,t he barriers which young men are confronted by,when consulting for SD issues.In this matter,male adolescents preferred not to discuss these types of problems and will do so only if they think that the problem is serious, long-lasting and perceived as physical (vs psychological).In that way,t hese results are consistent with a previous study concerning general sexual issues [20], which showed that while most adolescents believed that it is important to get help for health scenarios in general this is not the case for sex.Embarrassment at describing intimate topics in face-to-face settings, personal pride, and sense of masculinity represented important barriers in disclosing such problems.Similarly,previous studies among male adolescents determined that factors associated with a lower likelihood to consult included holding more traditional masculine beliefs [21][22][23].Moreover,even if they wanted to talk about SDs, young men did not necessarily know whom to address, and especially in anonymous ways.The second key finding of our study is the unanimous consideration of the Internet as a perfect initial step in dealing with a problem and an easy information research tool for any topic.
Participants stated that a problem which is long-lasting, is a criterion to consult.This represents an important result as waiting to consult can have significant consequences on sexual health.This is similar to what is known concerning adolescent men who, in general, seek health care scarcely and wait until a problem becomes serious [24,25].Also, not knowing whom, where and how to consult stood out as another barrier and raised the question of accessibility and adaptability of consultation places for young men.Although it is recommended that all adolescents from ages 11 to 21 should be asked annually about sexual behaviors [26], neither the men themselves nor their providers receive clear messages about the types of services that should be offered, or how often they should receive them [6].
Participants mentioned the importance of having a valid reason to consult and in particular a somatic one.However,aSwiss survey among adolescents has shown that a majority of male adolescents (74.6%) had consulted a GP at least once in the past year [27].Literature also highlights a discrepancy between youths' expectancies about a consultation and what GPs actually discuss during that period.A study showed that the topics adolescents would prefer discussing with their GP were sexuality,c ontraception and relationships [28].However,although young men want to talk about sexuality-related issues, if the professionals do not raise the question,the patients themselves arevery unlikely to do so.Hence, efforts need to be made among HPs to take advantage of this high consultation frequency and of any consultation opportunity to systematically inquire about sexuality in order to leave an open-space for discussion and detect 'hidden agendas'.This systematic psychosocial anamnesis can encourage young males to discuss SD issues with their primary source of care.Furthermore, periodic screening for young men might provide an important incentive for consultations in case of problems at another time, as described in the literature [22].
The Internet resource received high marks overall.Indeed, more and more young people turn to the Internet to get information on health matters [29]; it is used either as an information tool or in an interactive way to ask questions and receive personal answers tailored to their specific needs [18].Although the Internet cannot replace an inperson consultation, the screen and the keyboard have the advantage of anonymity,t hus avoiding embarrassment and pride is not challenged.Knowing that nowadays, 91% of youths aged 14-19 years use the Internet regularly in Switzerland [30], Web-based tools together with other new technologies should continue to be developed in a secure manner as a space for information, prevention messages and initial advice, which can then guide youths to appropriate resources.The Internet can serve as a useful supplement to existing health care services and its development can lead to a safe use through reliable Web sites [29,[31][32][33].As recent literature shows, the potential benefits of providing online health services include improved health care access, health literacy and ongoing care [34].The potential benefits are considerable and supported by our results concerning the use of Internet as an initial step to solve SD concerns.
There are nonetheless some limitations to our study.Firstly,this research corresponds to a pilot study; therefore the number of FGs is limited and questions only students.Secondly,the snowball effect in recruitment could have the disadvantage of gathering people from the same milieu who would have agreater chance of sharing opinions.Thirdly, working with scenarios did not produce data on participants' own experiences but only on hypothetical situations to which they might not have been confronted.Nevertheless, this method gives a positive incentive to raise the theme of sexuality.Finally,using FGs can also silent individual voices of dissent through peer-pressure and group norms [16].However,it has been previously shown that the group effect is positive for disclosure among youths concerning research on sexual behavior [15,16].

Discussion
Despite these limitations, this study highlights important barriers for young men to consult for SDssuch as embarrassment, pride and masculinity in face-to-face settings.HPs need to communicate clearly that these issues can be discussed confidentially in order to make it more socially acceptable for males to disclose these questions; and wherever young men consult and for whatever problem, sexual health must be on the agenda.This research brings a new insight into the use of the Internet by adolescents as a first step in addressing sexual health issues which future research should examine in more detail.Finally,I nternet-based tools need to be developed in order to become an easy access door -although not a substitute -to sexual and reproductive health services for young men.
Example quotes a) Maintaining intimacy "In my opinion, an answer from the Internet enables me to keep a certain intimacy."b) Preserving anonymity "When using the Internet, there is no need to reveal one's real name, not even to the doctor; it can simply be a pseudo."c) Protecting one's pride "It enables me to keep a certain amount of pride [because it is anonymous]."d) Giving the feeling of freedom "[Given that intimacy and anonymity are preserved,] one feels more freedom."e) Providing information at no cost "[Compared to going to see a doctor,] it's free!"