Are testosterone levels affected by circumcision?

Boy Medicine - Did You Know?

Boy medicine check - test your knowledge (tick):
(Resolution in text)

The There are no boys - just as there are no other sexes that can be generalized.
illustration 1 illustrates the different living environments of young people between the ages of 14 and 17 from the point of view of education and normative basic orientation1) and applies not only to young people in general but also to boys in particular. Archaic role models persist in our society as well. Boys are often said to be loud, wild and aggressive, chaotic and troublemakers. But is there really that “typically young”?

What shapes boys - testosterone - "the wild guys"

Much and much nonsense has already been written about testosterone - especially with regard to aggression and violence. It is overlooked that this hormone can promote fair behavior if this serves to secure one's own status. It was also found to promote honesty and prosocial behavior. Testosterone is used to secure status and is primarily a "social hormone". In the socially complex human environment, it is not aggression, but prosocial behavior that secures the status in the long term. "Life is a team sport"2, p. 75) and oxytocin and testosterone are the “global players”. Both promote bonding and relationship behavior and relationships within and to the peer group (“to connect more effectively with one another” - ibid.). You are among other things essential for peer contacts and peer interactions.

Male - being man - masculinity

Male means the biological male gender (genetics). Being a man represents the diversity actually lived - WHO or HOW am I / I feel as a man (gender). The term “masculinity”, on the other hand, describes the sum of the characteristics that are considered characteristic of a man. It is a cultural-ideological construct and is in tension with the lived “manhood”. Many boys - especially from the lower social classes - express their masculinity through their bodies3, pp. 101,103,119). For them, their body is often the only capital they have. In the context of migration, too, people often become independent and “masculinity” is celebrated as a dynamic means of coping and self-assertion in relation to the indigenous culture of the same age (peer culture) 3, pp. 165,167). Masculine dominance and demarcation behavior becomes a self-esteem stabilizer.

sexuality

With puberty, sexuality for most boys - regardless of their sexual orientation, sexual preferences, practices, desires, etc. - is an essential element of their everyday sexual practice and their male self-image. In a heterosexual relationship, girls and boys agree: the boy is responsible for the success of sexual interaction. Unlike girls, however, boys are only reached to a limited extent by medical sexual information and counseling. For boys, doctors are not important people they can confide in on issues of sexuality4) . Reproductive sexuality is a central moment in conceptions and ideologies of masculinity5) . Therefore, not only the WHO has started to focus on boys and men in contraception planning6-9) . In addition to the typical masculine stages of risk behavior, the sexual risk behavior of boys has direct consequences for the reproductive health of girls. Although the latter are seen by both sexes as primarily responsible for contraception, the boy still has a significant influence on contraceptive behavior.

Whenever possible, any health advice for boys should therefore be used to talk about contraception. This also includes information on vaccinations, such as the hepatitis B vaccination and the HPV vaccination. It is also a great advantage when girls bring their boyfriend along to talk about contraception and thus involve them in contraception planning. This promotes communicative competence on this topic, especially among boys (keyword: paternity contraception). The trusting and open conversation about sexuality in families is also very well suited to create closer and more trusting contact between young people and their parents10).

homosexuality

There is still a clear discrepancy in the public acceptance of homosexuality among male versus female adolescents. This is expressed, for example, in the reaction to the visibility of homosexuality in public11). If two men show their affection in public, e.g. by kissing, this is far less acceptable than if women show this behavior. The young people are well aware of this problem. A study by Krell shows the living situation and experience of discrimination of homosexual young people in Germany12) a time difference between the inner (mean age 13.5 years) and the outer coming-out (mean age 16.7 years) in homosexual / bisexual boys of 3.2 years (girls 0.9 years). The time between the inner and outer coming-out must be viewed as a very vulnerable and problematic phase of life. The suicide rate is significantly increased (up to 7 times), experimentation behavior with a transition to risk behavior increases and the risk of bullying increases significantly. To make matters worse, homosexual adolescents rarely seek the care of doctors with questions about their coming out. With boys in particular, it is therefore important to pay attention to possible hidden agendas every time they visit the doctor (e.g. unclear chest pain, depressive mood, etc.). Despite all the seemingly increasing acceptance of different sexual orientations in our enlightened Western society, it is still not possible to adequately accompany young people (especially males) with a coming-out problem.

Risk behavior

Boys show more externalizing risk behavior (linked to masculinity). The "intensity" dimension plays a major role here. At the same time, peer pressure increases individual engagement in dangerous activities. The socialization in the peer group thus leads to individually increased risk behavior. In addition, the social orientation towards the peer group increases negative feelings and aggression.

Risk literacy promotion

Preventive measures often ignore the boys' self-perception. As a rule, they are very well aware of the risks involved in their actions. Therefore not taking these risks does not fit with their self-concept of masculinity13). Male adolescents have more to gain than to lose through risk behavior, because success increases their attractiveness and ultimately their reproductive success14, p. 89).

"Given the importance of risk behaviors for being masculine, it is an illusion to believe that boys can be deterred or that their risk behavior can be prevented!"15). Rather, the key word is acquiring risk expertise.

Promoting risk literacy among boys means:

  • The ability of boys to seek, find or develop risks that are situational, socially and individually appropriate and that promise an individual or social benefit.
  • The ability of boys to adequately perceive and assess these risks.
  • The ability of boys to get through risks and to cope with them successfully or, if necessary, to break off in good time.
  • The ability of boys to take protective measures appropriate to the level of risk involved, i.e. to understand and implement protective competence as a risk-protection balance16).

All medical contacts can and should be used to build relationships. It plays a major role here to make it clear that you are interested in the concerns of boys and have expertise in young medicine. In case of doubt, the available book and flyer material can help (Stier and Winter 2013, Stier 2017, https://www.bvkj-shop.de/infomaterial.html). Especially with boys with their skepticism about the health system (illness is unmanly and health a matter of course), building relationships and empathy are a very important basis for medical intervention.

What do boys need - and expect - from us pediatricians?

  • Secrecy and empathy.
  • Enough opportunities to talk about your questions and doubts.
  • Doctors with young medical expertise and trained staff to get relevant and meaningful information within easy reach.
  • Gender-specific information about boys and girls about sexual and reproductive health and health in general.
  • Contact with messages and role models that support gender-equitable interaction with girls, especially with regard to gender stereotypes, attitudes towards sexuality and sexual behavior.
  • Free access to condoms and awareness of sexually transmitted diseases including knowledge about HIV / AIDS risks and HPV chlamydia infections as well as information about vaccinations and other protection options.

If we manage to meet these expectations, we have gained a loyal clientele and will certainly feel the gratitude one or the other time that someone is finally available to take care of their concerns.

Disease pictures - briefly the essentials (a small selection)17)

Justin (15 years old) comes into the practice with an unclear "pull" in the right groin. He recently had a girlfriend. These frequently expressed complaints open up a wide range of medical considerations.

In terms of differential diagnosis, the following must be considered, among other things:

  • Inguinal hernia.
  • Muscle or tendon injuries (e.g. athlete's groin).
  • Joint disease.
  • Inflammation of the nerves.
  • Diseases of the urinary organs (e.g. urinary stones).
  • Reproductive system disorders (e.g. testicular pain).
  • Lymph node swelling (e.g. caused by infections, in rare cases by tumors).

A “hidden agenda” is often hidden behind the symptoms described. This ranges from the “hidden” request to examine the genitals because the boy has noticed something conspicuous, to concerns about the penis size being too small - as in our case. Therefore, in the case of "groin pain" and abdominal pain, the genital area should always be included in the examination. Taking the complaints seriously and emphasizing how responsible it was to go to the ordination is an essential basis of the doctor-patient relationship.

Balanitis (actually Balanoposthitis) - What You Should Know

  • Inflammation of the inner foreskin and glans penis (balanoposthitis).
  • Often with existing phimosis / scar phimosis.
  • Candida albicans very common / intestinal germs.
  • Associated with diabetes mellitus, sexual intercourse with an infected partner - (also think of anal intercourse).
  • Consider STD => smear! - Beware of chlamydia: there are no valid data for boys, approx. 10% for 17-year-old girls - a similar prevalence for boys can be assumed.
  • Therapy:
    • Antimycotics / antibiotics locally (and possibly systemically).

Note:

  • Consider partner treatment.
  • Think about the condition after anal intercourse.

Phimosis: when, what, how to do (German Society for Pediatric Surgery 2017):

  • Primary “real” phimosis: approx. 0.6% - 1.5% (rest mostly “physiological phimosis” => wait).
  • Histological evidence of lichen sclerosus is found in up to 34% of all foreskins that have been removed due to pathological phimosis.
  • Therapy during puberty: primarily treatment with cortisone ointment (e.g. betamethasone 0.1%; mometasone furoate 0.1%, clobetasone 0.05%) for approx. 4 - (8) weeks / success rate: 60 - 70% - success is then achieved through regular hygiene measures .
  • Indications for circumcision - only with persistent complaints / after unsuccessful conservative therapy:
    • Condition after paraphimosis (relative indication).
    • Permanent micturition obstruction / micturition problems with persistent ballooning and weakened urine stream.
    • Cohabitation obstacle / cohabitation problems.
    • Z.n. recurrent balanitis with scarring / micturition problems.
    • Lichen sclerosus (histology!).
    • Relative indication: high-grade vesicoureteral reflux, complex urinary tract malformations, neurogenic bladder emptying disorders with recurrent urinary tract infections.
  • Contraindications (Note hypospadias, epispadias, congenital penile deviation, etc.).
  • Complications 2% - 10%!
    • Post-hemorrhage is most common (still 5% under optimal conditions).
    • Damage to the glans rim / meatal stenosis (especially in infancy up to 20%).
    • Castration trauma / post-traumatic stress disorder / orgasm disorder.
  • Foreskin adhesion is NOT a phimosis and does NOT require any therapy!

Note:

  • Before performing a circumcision (Europe-wide 10-15%), it should be explained that the loss of skin resulting from the circumcision can lead to a loss of sensitivity, which in turn may affect later sexual life.
  • Circumcision can lead to orgasm problems and disorders, as well as dyspareunia.
  • In Western Europe, (routine) circumcision should not be carried out as a preventive measure to prevent infection with sexually transmitted diseases (also applies to HIV).
  • (Routine) circumcision should not be performed as a preventive measure with regard to the development of penile cancer.

Lichen sclerosus (German Society for Pediatric Surgery 2017)

  • Chronic inflammatory, non-contagious skin disease (rarely before age 6).
  • In boys, the penis is almost always affected with shrinkage of the foreskin => foreskin constriction.
  • The importance of the disease is underestimated in boys and is often overlooked or not recognized.
  • Histologically proven in up to 34% of all circumcisions due to pathological phimosis!
  • Meatus tightness as a possible complication.
  • Therapy:
    a) With cortisone ointment (e.g. clobetasol propionate 0.05% - period of up to three months, applied locally once per day) or calcineurin antagonists (off-label use).
    b) If local therapy fails => complete circumcision.

Note:

  • Lichen sclerosus is not a precursor to cancer, but is a benign chronic skin disease with predominantly anogenital involvement. However, there is an increased risk of developing penile cancer later in life (> 30 years). An HPV infection could be a (co-) cause here. This underscores the need for HPV vaccination in all boys too.

Hypospadias (Riccabona 2012, Adams and Bracka 2016, Winship et al. 2017, Ruppen-Greeff et al. 2015)

  • The time of correction is given in the literature as “ideally between 12 and 18 months of age”. Optimally, however, would be an operation between the 9th and 12th month of life. The time window from sexual identity development, cognitive and emotional development plays a role here. In any case, the correction should be completed in the 2nd year of life.
  • Uncorrected hypospadias seldom in adolescence (immediate urological treatment) - but to be expected more frequently in adolescent migrants, as the genital area is more taboo and the parents are usually not aware of the disease (socio-cultural reasons?).
  • Proximal hypospadias should always be subjected to an extended diagnosis.
  • Possible consequences: Psychosexual impairment, later difficult sexual contacts due to shame because of the "otherness" of the genitals.
  • Therapy:
    Surgical / local pretreatment with dihydrotestosterone gel / cream (reduces complication rate). If the correction is successful, sexual function is not impaired.

Note:

  • The hypospadias is often associated with a curvature of the penile shaft, meat stenosis, a foreskin apron and an undescended testicle (Maldescensus testis).
  • Any hypospadias, even if there is only a gaping preputium, should be referred to a pediatric urologist or pediatric surgeon at least once, since concomitant diseases such as penile deviation or meatal stenosis cannot be ruled out.
  • For a functionally and cosmetically optimal result, a hypospadias correction should always be carried out in a pediatric surgery and pediatric urology center with the appropriate experience.
  • The greater the cosmetic and functional impairment and the deviation from the normal findings, the more urgent the indication for surgery.
  • As before, psychological and psychosexual aspects of hypospadias are discussed too seldom - despite its relative frequency.It makes sense to provide good medical and, if necessary, psychological support for the patient, including post-operative care.

Testicular torsion (AWMF S2k guideline 006/023)

  • The "acute scrotum" is always an emergency (approx. 25% testicular torsion as the cause).
  • The frequency of testicular torsion peaks in the first year of life and during puberty.
  • 10-fold increased risk in testes after delayed descent.
  • Increase in pain when the scrotum is lifted (Prehn's sign, very unreliable!).
  • A maximum of 6 - 8 hours remain for diagnosis and targeted therapy.
  • Leydig’s interstitial cells - ischemia time approx. 12 hours!
  • An atrophic but palpable testicle does not have to be removed.
  • A contralateral testicular damage can result from an antibody-induced immunological process of the left incarcerated testicle.
  • Therapy:
    a) Operative with orchidopexy. Prophylactic orchidopexy of the opposite side should be carried out promptly in the event of testicular torsion.
    b) Manual detorsion with secured testicular torsion is reserved for out-of-hospital emergencies or foreseeable delays in surgical treatment.

Note:

  • Unexplained abdominal pain is still one of the most common anamnestic information in the presence of testicular torsion. Not including the genitals in the examination for this reason is a medical malpractice. There is a clear peak in frequency with around 65% of cases between the ages of 12 and 18. The risk here is 1: 4000 and accounts for around 25% of all acute scrotum cases. Intermittent torsion events are already described from the age of 8.
  • Restitution occurs in 80 - 100% if the blood flow was not interrupted for more than approx. 6 hours.
  • The final recovery of the testicle can be seen after approx. 5 - 8 weeks.

Undescended testicles - Maldescensus testis (Ludwikowski B. (coordinator) (2016) S2k guideline 006/022)

  • Incidence of 0.7 - 3% in boys born mature, up to 30% in premature babies => most common congenital anomaly of the urogenital tract (consider syndromic diseases).
  • In about 1.5% there is an undescended testicle in childhood and adolescence (mostly due to the transition from a pendulum testicle to a sliding testicle due to secondary ascension).
  • Insufficient testicular decline => part of a primary damage => fertility disorder, increased malignancy rate, etc. - secondary damage caused by being left in the wrong position (in men with unilateral undescended testicles, the paternity rate (89.7%) is the same or at most 4% lower than in the normal population)
  • No hormone therapy after the first birthday (success rate in the first year of life only approx. 20%).
  • Pendulum testicles require regular control (risk of secondary ascension 2 - 45%). As a result, there is a risk of developing a sliding obstruction with the risk of secondary damage (impaired spermiogenesis).
  • Therapy:
    a) Hormone therapy only in the 1st year after the 6th LM - after that no hormone therapy is indicated.
    b) After the 1st year: orchidopexy.
    c) If the position is intra-abdominal, laparoscopy is the method of choice.
    d) Control of the success of the operation every 3 months in the 1st postoperative year.
    e) Testicular biopsies for undescended testicles are routinely not indicated.

Note:

  • Per se, with the formerly primary undescended testicle, there is a 1.5 to 7.5-fold risk of testicular cancer compared to the normal population. If the orchidopexy is not performed until after the age of 10, this risk increases in the form of a logarithmic increase from 2.9 times to up to 32 times in the later correction age. So: the later the orchidopexy, the greater the risk of malignancy.
  • In bilateral primary undescended testicles, fertility is significantly reduced.
  • A renewed ascension of the testicle occurs in approx. 25%. Parents should be informed about the success rate.
  • Regular self-examination after the age of 15 because of the risk of malignant degeneration (see above).

Varicocele (see also Joustra et al. 2015 for testicular volume determination) (15-20%)

  • Differentiation into primary (left) and secondary (right) varicocele.
  • Ultrasound examination lying down and standing / Valsalva attempt => clear protrusion of the congested venous plexus.
  • Mostly accidental discovery.
  • Depending on the degree of the varicocele, a pathological spermogram can be detected, Leydig cell function also impaired -> testosterone may be reduced.
  • "Spontaneous healing" / regression in approx. 70% - the higher the degree of varicocele, the less likely it is.
  • Surgical indication (EAU Guidelines on Pediatric Urology 2016):
    a) Difference in size of the testes> 2 ml (> 20%) or growth arrest on the affected side.
    b) Additional testicular pathology.
    c) Bilateral palpable varicocele.
    d) Pathological inhibin B values ​​(FSH less precise) or pathological spermiogram.
    e) Symptomatic varicocele.
  • No indication for surgery:
    a) Asymptomatic varicocele with azoospermia.
    b) Child's varicocele with normal testicular volume => control every 6 months / semen analysis / possibly inhibin-B.
    c) Varicocele grade 1 and 2.

Note:

  • After surgery, increase in testicle volume / improvement in sperm quality and number as well as increase in testosterone / inhibin B increase possible.
  • The higher the varicocele, the greater the impairment of sperm concentration and quality (grade 2: 40% lower sperm quality, grade 3: 55% lower sperm quality).
  • The aim is to eliminate varicose veins and maintain fertility.
  • Due to improvements in ultrasound diagnostics, more and more secondary varicoceles are being diagnosed without a tumorous process being found as the cause of the congestion.

Spermatocele

  • Retention cyst of the spermatic duct (DD funiculocele: accumulation of fluid in the area of ​​the spermatic cord).
  • Localized on the head of the epididymis.
  • Contains sperm.
  • Usually small and relatively firm - possibly larger and imposing like a “third testicle” (transillumination).
  • Relative surgical indication:
    a) Persistent pain and very annoying size.

Note:

  • The spermatocele is usually completely harmless and does not cause any symptoms. Their discovery points to the boy's self-examination (commendable!).
  • The diagnosis can be made quickly using ultrasound.
  • Surgical rehabilitation leads to sterility with a high degree of probability!

Testicular microlithiasis

Testicular microlithiasis (TM) is a rare, mostly bilateral ultrasound finding in boys and men. Whether the testicular microlithiasis is the result of a multifocal Sartoli cell dysfunction is so far only one hypothesis. The increasing frequency of sonographic examinations of the testicles and the increasingly better ultrasound devices make this chance diagnosis more frequent. The incidence is given as 1.7 - 1.9%.
The combination of TM with other diseases of the male genitalia (hydrocele, varicocele, epididymitis, testicular atrophy and germ cell tumors) is striking.

  • Rare, mostly bilateral finding (incidence ~ 1.7 - 1.9%) and the discovery is mostly accidental.
  • Etiology unclear.
  • Not a precancerous condition per se.
  • Very rarely associated with malignant testicular disease in childhood.
  • Restriction of fertility? (not yet proven).
  • If TM is present: annual ultrasound checks and, if necessary, determination of AFP and HCG, possibly testicular biopsy (only in the case of focal parenchymal lesions / changes in echogenicity).

Note:

  • A connection between TM and tumor development has not yet been proven with certainty.
  • There is evidence that the presence of bilateral testicular microlithiasis results in an increased tumor risk in subfertile patients. At what intervals these patients should be re-examined or whether a biopsy is appropriate must be clarified in larger, prospective studies.
  • There is no specific therapy.

Hirsuties papillaris penis

  • In about 15-25% of boys through puberty.
  • Not related to sexual activity.
  • DD: Mollusca contagiosa, lichen planus, bowenoid papules, condylomata acuminata and condylomata lata (syphilis).
  • Histologically connective tissue.
  • Therapy:
    a) Primarily none required.
    b) Surgical intervention only extremely cautious (Co2 laser treatment), risk of scarring on the corona (loss of sensitivity!).

Note:

  • Although completely harmless, the connective tissue papules can be very annoying and frightening to the boy (also with regard to the presence of a sexually transmitted disease). If necessary, partner counseling is therefore indicated.

Penis deviation (penile bending, penis curvature, penis curvature)

  • Relatively often - high number of unreported cases.
  • Innate:
    • For example, also in the context of hypo- or epispadias.
    • Asymmetrical development of the penis tissue => cavernous bodies are e.g. unequal in size or shortened.
  • The angle of curvature does not change during puberty.
  • Possibly developmental disorder (temporary testosterone deficiency 4th SSM?).
  • Acquired:
    • Induratio penis plastica (IPP) or penile fracture - mostly affects men 40 to 60 years of age.
  • Therapy of congenital penile curvatures:
    a) As long as no complaints and GV possible without any problems => NONE.
    b) Clinically relevant => with physical limitations (e.g. from an angle of curvature> 30 degrees).
    Operational (cave risks!):
    - Only in the event of pain or significant restrictions (e.g. during sexual intercourse).
    - No correction for cosmetic reasons!

Note:

  • Discussed again and again in forums. There is a high number of unreported cases of congenital penile deviation.
  • The curvature itself is the main symptom. Complaints are rare.
  • A reason for introducing yourself can be if there are problems with intercourse. A deterioration in the angle of curvature is not to be expected after the penis has grown.

Shortening of the foreskin ligament

  • Shortening of the foreskin ligament between the inner foreskin side and the anterior side of the penis
    - Congenital
    - Condition after tearing => scar (if there is a tear, more bleeding is possible)
  • There are no known data on the frequency.
  • Leads to uncomfortable pain and curvature of the glans penis (especially during sexual activity).
  • Therapy:
    a) Conservative with ointment containing cortisone.
    b) Operational:
    - frenulectomy (removal)
    - frenulotomy (transection)
    - Frenuloplasty (extension)

Klinefelter Syndrome (XXY) (www.klinefelter.de) - Frequency: 1: 500 - 1: 1000

  • As a rule, unfortunately, the diagnosis is only made after puberty in the fertility clinic (70 - 80% not recognized early!).
  • Early signs:
    • Small genitals, initial testicle growth up to approx. 6ml, then growth arrest (small solid testicles during puberty).
    • Increased growth in height after starting school (strong increase in leg length), slightly delayed language development, concentration disorders and learning problems.
    • Associated disorders:
      Lack of drive, gynecomastia, tall stature, undescended testicles, poor contact, learning difficulties, motor disorders, low muscle tone, osteopenia, speech development delay, testosterone deficiency, delayed puberty, possibly fertility.
  • Later signs of testosterone deficiency:
    • Disorder of libido and potency, dtl. limited spermiogenesis, unfulfilled desire to have children (> 90% the syndrome remains undetected!), sparse body hair and beard growth, tendency to gynecomastia, female fat distribution, small testicles (cave testicle volume <6 ml!).
    • Increased thrombosis, varicose veins and inflammation.
  • 15 - 50 times higher risk of breast cancer compared to the normal collective: early testosterone therapy (Depot preparation) - lifelong: => German decreased signs of testosterone deficiency syndrome, osteoporosis prevention.
  • Recommendation for the removal of the mammary gland in gynecomastia (risk of degeneration corresponds to the risk of female breast cancer).
  • Fertility is possible through ICSI (intracytoplasmic sperm injection) => testicular sperm extraction IN FRONT Consider the start of treatment!

Note:

  • In principle, patients with Klinefelter syndrome should be advised just as much with regard to the creation of a fertility reserve as oncological patients, for example.
  • An early diagnosis is essential (unfortunately so far seldom).

"Boys matter too and are in danger of being left behind"
(The Lancet: Editorial of the December 2015 issue)18)

Men's health begins with boys' health. Taking care of young medicine and boy health issues competently is a central issue of the 21st century. So let's get on our way together!

References (further literature available from the author)

  1. Langer J., Thomas P.M. (2016) Young Living Worlds: Findings from the SINUS Youth Study 2016 (Part 1). energy | water practice 8/2016
  2. Shatkin JP (2017) Born to be wild. Why teens take risks, and how we can help keep them safe. Penguin Random House, New York
  3. Böhnisch L (2004) Male socialization. Juventa Verlag Weinheim
  4. Bode H, Heßling A (2015) Youth sexuality 2015. The perspective of 14 to 25 year olds. Results of a current representative repeat survey. Federal Center for Health Education, Cologne
  5. Gilmore D (1991) Myth Man. Roles, rituals, models. Artemis Winkler, Munich
  6. Barker G, Ricardo C, Nascimento M (2007) Engaging men and boys in changing gender-based inequity in health: Evidence from program interventions. World Health Organization, Geneva 2007. http://www.who.int/gender/documents/Engaging_men_boys.pdf Accessed March 11, 2019
  7. Ringheim K, Feldman-Jacobs C (2009) Engaging Men for Gender Equality and Improved Reproductive Health. Population Reference Bureau (PRB), with appreciation for the contributions of Michal Avni and Patty Alleman, USAID’s Office of Population and Reproductive Health
  8. Raju S, Leonard A (2000) Men as Supportive Partners in Reproductive Health. Moving from rhetoric to reality. Population council South and East Asia Regional Office
  9. WHO (2000) Boys in the picture. http://www.who.int/maternal_child_adolescent/documents/fch_cah_00_8/en/ Accessed March 11, 2019
  10. Marcell AV, Wibbelsman C, Seigel WM, the Committee on Adolescence (2011) Male Adolescent Sexual and Reproductive Health Care. Pediatrics 2011; 128: e1658 – e1676
  11. Federal Anti-Discrimination Agency 11018 Berlin (2017) Attitudes towards lesbians, gays and bisexuals in Germany, results of a representative survey. https://www.antidiskriminierungsstelle.de/SharedDocs/Downloads/DE/publikationen/Umfragen/Handout_Themenjahrumfrage_2017.pdf%3F__blob%3DpublicationFile%26v%3D3 accessed on 11.03.2019
  12. Krell C (2013) Life situations and experiences of discrimination among homosexual adolescents in Germany. Final report of the pilot study. DJI e.V.
  13. Diagnosis boy! Pathologization of a Gender? BPtK symposium on June 3, 2014 in Berlin. https://www.ptk-nrw.de/de/aktuelles/nachrichten-2014/detail/article/diagnose-junge-pathologisierung-eines-geschlechtsbrbptk-symposium-am-3-juni-2014-in-berlin.html access 03/11/2019
  14. Hinz A. (2015) Health from an evolutionary psychological perspective. In: Blomberg C and Neuber N (2015) Male self-assurance in sport, Wiesbaden, pp. 77-96
  15. Winter R (2015) Lecture at the conference “Watch out or let go?” Of the State Association for Health Hanover, November 17, 2015
  16. Winter R (2015b) More Risk! More man? Published in: deutsche Jugend (DOI 2201512540), No. 9/2015, pp. 367 - 373 (Part I) and No. 10/2015 (Part II), pp. 436 - 442
  17. Manual boy medicine (Stier B - 2017). Springer Fachmedien, Wiesbaden ISBN: 978-3-658-17322-7

  18. Adolescent health: boys matter too - Editorial. Vol 386 December 5, 2015 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01160-5/fulltext, accessed on March 11, 2019

Some passages were taken from the detailed article "What boys need - promoting healthy development in boys" from Pediatric Practice 2019 (also by Dr. Stier). A written declaration of consent from the publisher of this journal is available for this manuscript.

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