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Sexually transmitted infections (STIs) in men can be caused by bacteria, viruses, or parasites. Patients present primarily with urethritis or skin manifestations. The most common STIs affecting men include gonorrhea; chlamydia; Mycoplasma and Ureaplasma infections; trichomoniasis; syphilis; chancroid; mpox (monkeypox); and infections with human papillomavirus; herpes simplex virus; hepatitis A, B, and C viruses; and HIV. Primary and secondary prevention strategies include vaccination, preexposure prophylaxis, condom use, and routine screening to reduce transmission and improve clinical outcomes. A thorough sexual history should be obtained from patients using the Centers for Disease Control and Prevention's 5Ps framework (ie, partners, practices, protection from STIs, past history of STIs, pregnancy intention). The National Coalition for Sexual Health has suggested a sixth P-plus-that represents pleasure, problems, and pride. The latest recommendations for prevention measures include doxycycline postexposure prophylaxis (doxy PEP) for certain high-risk groups.

Infertility is defined as failure to achieve pregnancy after 12 months or more of regular, unprotected intercourse. Infertility is presumed after 12 months when the female partner is younger than 35 years, and after 6 months when the female partner is older than 35 years. Couples attempting to conceive should be encouraged to engage in intercourse every 1 to 2 days and can track ovulation to maximize the likelihood of conception. Evaluation of male infertility should include assessment for underlying medical conditions that may affect fertility and at least one semen analysis. Approximately 25% of couples have unexplained infertility. Assisted reproductive technology can be used to achieve pregnancy, including for couples who do not have an identified cause of infertility. Low libido in men is a poorly understood phenomenon that is underdiagnosed in clinical practice. The degree of distress associated with lack of sexual desire is essential to the diagnosis. The Sexual Desire Inventory-2 can be used to initiate discussion with patients and assess libido. Clinicians should rule out factors that can contribute to low libido (eg, endocrinopathies, testosterone deficiency, mental health conditions, relationship issues) and support patients in achieving their goals regarding sexual health. Testosterone replacement therapy should be considered for men with low libido and testosterone deficiency.

Erectile dysfunction can result from organic, psychogenic, or substance-induced causes. Phosphodiesterase type 5 inhibitors are the mainstay of medical treatment, although other medications and interventions, such as intracavernosal injection therapy and constriction devices, can also be used. Priapism is defined as a prolonged erection of the penis continuing after or irrespective of sexual stimulation. It may result from conditions causing ischemic states or dysregulation of arterial inflow. Acute ischemic priapism is a medical emergency and can result in irreversible erectile dysfunction. Nonischemic priapism is not an emergent condition and should resolve spontaneously. Phimosis, or inability to fully retract the penile prepuce over the glans, is a congenital or acquired condition and can cause discomfort. Physiologic phimosis usually resolves by age 16 years, whereas pathologic phimosis may require circumcision for definitive treatment. Paraphimosis, an emergent condition, results from the foreskin becoming trapped proximal to the coronal sulcus. Treatment consists of manual reduction. In Peyronie disease, fibrous plaques develop in the penile shaft, subsequently causing deformity of the penis when erect. Surgical and nonsurgical treatment options, such as collagenase or intralesional injections, are available.

Disorders of ejaculation include premature ejaculation, delayed ejaculation, retrograde ejaculation, and hematospermia. Lifelong premature ejaculation is defined as ejaculation always or nearly always within 1 minute of vaginal penetration that has been present since the first sexual encounter. Acquired premature ejaculation typically begins after a period of normal function, with ejaculation occurring within 3 minutes of penetration. Treatment options include medications and behavioral techniques. Selective serotonin reuptake inhibitors and tricyclic antidepressants are first-line drugs. Delayed ejaculation applies to a range of issues, from delay to complete absence of ejaculation. Guidelines suggest use of an ejaculatory latency time greater than 25 to 30 minutes for diagnosis. Etiologies include psychological and organic factors, such as adverse effects of medications. Treatment focuses on causal medication discontinuation, psychological interventions, and use of off-label drug therapy. Retrograde ejaculation occurs when semen enters the bladder due to an anatomic, neurogenic, or pharmacologic cause. Treatment options include sympathomimetic medications and surgical correction of anatomic abnormalities. Hematospermia, or blood in the semen, is generally benign and self-limited. However, underlying malignancy is possible and should be considered based on patient age and risk factors. Treatment ranges from reassurance to management of the underlying cause.

The health impact of the conditions in which people are born, grow, work, live, and age have been recognized for centuries. However, widespread acceptance of this impact remains contentious, as inequities in morbidity and mortality represent the enduring legacies of displacement, oppression, and systemic discrimination. The World Health Organization estimates that social and structural determinants are responsible for 30% to 55% of all health outcomes. Social determinants of health, structural determinants of health, structural violence, and the need for structural competency are four codependent concepts that must be explored together to develop responsive clinical interventions. Social and structural determinants of health include wealth and social status, geography and neighborhood, employment and labor, and education. Racism is a major driver of social and structural determinants of health in the United States. It is important to differentiate between upstream and downstream approaches to addressing health inequities because addressing upstream factors has a greater impact.

Despite extensive research documenting the potential of diversity, health equity, and inclusion initiatives to improve outcomes for the most vulnerable patients, attacks on these efforts in both private and public sector health care institutions are proliferating. Given demographic trends in the United States, diverse health care teams are a strategic necessity to bolster the experiences and outcomes of marginalized patients, foster inclusive research and innovation, and lower health care expenditures. To create diverse health care teams, physicians and allies must deepen their understanding of the complexities of structural racism and address the socially imposed forces that persist and result in the loss of underrepresented minorities on the path to health careers. Practicing physicians and other health care professionals can individually and collectively contribute to the development, recruitment, and retention of a more diverse and inclusive workforce to serve all patients. Strategies that physicians can use to achieve this goal include making diversity core to the practice's mission, focusing on retention, connecting with local school districts and colleges, and striving for more equitable policies and procedures.

Seeking heath equity means striving to give everyone a fair opportunity to be as healthy as possible by working to eliminate health disparities and determinants that adversely affect certain groups. An alternative framework is to define health equity by quality of outcomes. Numerous family medicine organizations have argued that health equity is central to the practice of medicine, adding convenience, cultural humility, structural competency, community engagement, and collaboration to the core tenets of primary care. Many family medicine educators have embraced a focus on health equity within practices as foundational to training future physicians. Aspects of the health care system that perpetuate inequity include fee-for-service payment models (which create untenable expenses for patients and pressure on clinicians to increase volume) and capitation models (which can lead to the underprovision of care for patients). Practicing care that is trauma- and violence-informed, culturally safe, and contextually tailored predicts better outcomes for patients and can help reduce moral injury for the clinician. Family physicians are uniquely positioned to work with patients, communities, and partners to create a more equitable health care system.

Modern medicine has developed over the past 2 centuries in societies stratified by race and ethnicity. Race-based medicine analyzes health risks and treatment based on a patient's race, often assuming that differences in health status are due to biology and genetics. In the United States, there is a history of guidelines using race-based decision-making for a variety of conditions (eg, hypertension, heart failure). These guidelines lead to profound health disparities. Genetic tests reveal precise molecular causes for differences in therapeutic and adverse effects of medications, and certain genetic variants are more common in specific groups of people. At the same time, there is growing evidence on health disparities that shows stratification of social determinants of health by race, ethnicity, income, and geography. Race-based prescribing guidelines and race-correction factors are under review across medicine to ensure that accurate data are used to provide unbiased care and that guidelines are not worsening health disparities. Race-conscious medicine focuses on the understanding that, although racial differences in health status may be influenced by genetics and epigenetics, they are just as likely to be due to racial stratification in access to resources, experiences of bias and discrimination, and social factors correlated with race.