To whom should a young male with recurring illnesses be referred?

Referral Recommendations for Young Males with Recurring Illnesses

Young males with recurring illnesses should be referred to an endocrinologist for evaluation of potential hypogonadism or other endocrine disorders as the first-line specialist referral. 1

Assessment Framework for Young Males with Recurrent Illnesses

Initial Evaluation

• Document associated clinical features including:
  • Secondary sexual characteristics development
  • Voice characteristics
  • Genital development
  • Muscle mass and fat distribution
  • Presence of gynecomastia

Laboratory Testing to Consider Before Specialist Referral

• Total and free testosterone levels
• Luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
• Thyroid function tests
• Prolactin levels

Specialist Referral Pathway

Primary Referral: Endocrinologist

• The British Journal of Dermatology recommends first-line referral to an endocrinologist for comprehensive hormonal evaluation 1
• Endocrinologists can assess testosterone levels and other endocrine parameters that may contribute to recurring illnesses in young males

Secondary Referral Options Based on Specific Presentations

1. Mental Health Professional

   • If screening reveals depression, anxiety, or other mental health concerns 2
   • Particularly important as mental health issues may present as recurrent physical complaints
   • Trauma-focused cognitive behavioral therapy has shown effectiveness for adolescents 2

2. Gastroenterologist

   • For recurrent gastrointestinal symptoms or positive celiac disease screening 2
   • Particularly if there is weight loss, failure to gain weight, or other nutritional concerns

3. Urologist

   • If structural abnormalities or urinary symptoms are present 1
   • May be needed for further evaluation of reproductive health concerns

4. Developmental-Behavioral Pediatrician or Child Psychiatrist

   • For evaluation of ADHD or other neurodevelopmental conditions that may manifest as recurrent health issues 2
   • ADHD should be recognized as a chronic condition requiring specialized care

Important Clinical Considerations

Addressing Barriers to Care

• Young males are less likely to seek medical care than females despite having similar health concerns 3
• Establish confidential care and create a welcoming environment for adolescent males
• Educate parents on the importance of regular health maintenance visits for their sons

Follow-Up Planning

• Quick and consistent follow-up increases compliance and engagement 2
• Consider the principles of the chronic care model and medical home for ongoing management 2
• Ensure continuity of care, particularly for youth transitioning between different care settings 2

Screening for Comorbidities

• Screen for eating disorders in underweight patients with recurrent illnesses 2
• Assess for substance abuse in adolescents before initiating treatment for other conditions 2
• Consider screening for celiac disease in patients with unexplained recurring illnesses 2

Pitfalls to Avoid

1. Delayed Specialist Referral

   • Adolescent males often present late in their disease course due to reluctance to seek care
   • Don't hesitate to refer when recurrent illnesses persist despite primary care management

2. Missing Underlying Endocrine Disorders

   • Absence of secondary sexual characteristics should prompt immediate endocrine evaluation
   • Hypogonadism may present subtly with recurrent illnesses before more obvious signs develop

3. Overlooking Mental Health Components

   • Mental health conditions frequently present with physical symptoms in adolescents
   • Failure to address underlying mental health issues can lead to persistent physical complaints

4. Scope Inversion

   • Avoid having specialists provide routine primary care that could be managed by primary care physicians 4
   • Ensure appropriate division of responsibilities between primary care and specialty care

By following this structured approach to referral for young males with recurring illnesses, clinicians can ensure timely and appropriate specialty care while maintaining the coordination benefits of the medical home model.