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Dealing with a young man worried about his 'tackle'

Case history

Simon is an introspective youth of 17. He lives with his mother, and his father died suddenly of a heart attack when he was nine. He has consulted you four times in the past six months for different problems, on the last three occasions without his mother.

At the first solo visit he complained of a sore throat, which looked absolutely normal on examination. He attends again and is rather hesitant about the reason. He is starting university and he has never had a girlfriend. He has never been away from home and he will be living on campus. He is worried that his penis is too small and he asks you if you could 'check out his equipment'. How do you handle this and future consultations?

Dr Michael Crawford

'Be sensitive to his concerns and reassure him, if all is well'

I should take this as a compliment that he feels able to confide his innermost concerns to me, even if it has taken four consultations to unearth this 'hidden agenda'. One must be sensitive to his concerns and reassure him, if all is well.

Simon's life to date sounds somewhat sheltered. He is about to leave the restrictions of home and the watchful eye of his mother. He is obviously considering his sexuality and has genuine concerns that at the vital moment he will be found physically wanting.

I would wish to know how long he has felt this way and on what basis he has concerns. Has he been teased at school or elsewhere?

After an examination I would aim to make him aware of the normal size range of 'his equipment' and if possible reassure him that he fell well within these borders.

I would also take the opportunity during the consultation to inquire about any other related concerns he might have.

I would wish to discuss contraception and STDs at this time.

Finally, I would try to exclude a depressive element by inquiring about sleep, appetite, energy, interests, mood and concentration.

The thought of leaving home may be weighing heavily on his mind and I would close the consultation by finding out a little about which course he hopes to study, where he wishes to study and his plans for accommodation, wishing him well for the future.

During future consultations I will be mindful of the chat we have had and will probably look for an undisclosed reason for attendance when one does not exist.

Dr Alison Best

'It would be appropriate to consider using chaperone'

On the face of it, his first three solo consultations could be considered as pretty much run-of-the-mill general practice and it could be over-analytical to attribute too much significance.

However, as GPs we do try to look out for a hidden agenda

and there are some pointers to a more complex underlying problem.

Having lost his father suddenly when he was nine years old, he may have some unmet psychological needs. In this context, repeated presentations with trivial complaints may be, in some way, a cry for help.

Today's consultation needs to be dealt with sensitively.

It will not have been easy for him to initiate this consultation. Equally, as a female GP, this may be a situation that makes me feel uncomfortable.

As ever, it is important to take a careful history, considering

both physical and psychological factors.

While it would be easy to pigeon-hole this case as psychological, it is important to exclude delayed puberty. Examining his genitalia would be part of the assessment.

It would be appropriate to consider using a chaperone. Is his development normal?

If there were any suggestion of organic disease I would investigate further. I would also try to provide a supportive environment for him to discuss any underlying emotional or psychosexual issues.

As far as future consultations, it is often difficult to provide continuity of care to students as they usually reregister with university health centres.

I would explain that it would be possible to see him as a temporary resident during the holidays.

Dr Rachel Pryke

'What do blokes expect us ladies to say anyway?'

Initially I would do some confidence-building groundwork, reminding him that relationships are rarely founded on physical attributes alone. Indeed, most girls fall for boys way before they have discovered what is hanging about downstairs, and vice versa.

I'd suggest he aim to be a good friend first and then see what happens. I would want to ask some direct questions about alternative potential worries, including an anxiety assessment and brief depression screen.

Are there unresolved bereavement issues, perhaps a looming sexual identity crisis or just old-fashioned nerves about the forthcoming major event of leaving home with untested kit in his suitcase? What about his own cardiac risk? Now doesn't seem quite the time to explore it.

Simon may find it helpful to understand that an accumulation of general worries can sometimes become focused on to one aspect, either psychological or physical, making that problem seem profound and blocking out all the other worries on the horizon.

Working positively through some general issues, for example leaving his mum on her own, managing finances by himself, coping with his workload and his confidence in making new friends may bring his main worry back into perspective.

He may be reassured by a frank discussion of penis size, although I'd hardly count myself the oracle on the subject. I suspect that some comprehensive counselling might be in order but may well herald the start of his psychosomatic career.

As for the actual examination, I would hope that he might feel the above groundwork had made an actual physical check unnecessary. In any case, what do blokes really expect us ladies to say?

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