Tuesday, January 25, 2011

Sports Physicals
Are They Needlessly Embarrassing?

Sports physicals are universally required in the U.S. on an annual or seasonal basis for students wishing to participate in sports.  All states have requirements covering public schools.  The reason for the exams is to ensure that the athletes can participate safely.   These exams are not intended to replace a regular physical.  There are no absolute standards for what should be included in these exams.  Most would agree that the emphasis should be on the cardiovascular and musculoskeletal systems.  The manner in which the exams are done is also not standardized.  Most schools will give students an option to see their private physician to have a form filled out; the private physician may elect to combine this with an annual exam.  Schools will usually offer a group examination which varies greatly in terms of how it is set up.  It could be one physician or nurse practitioner seeing the students one at a time; it could include multiple specialists seeing the students at different stations in a large area such as a gymnasium.  It often includes no provisions for privacy.

It is no secret that most children find these exams embarrassing as indeed they are likely to consider all exams.  But how embarrassing they are depends on how they are done.  All exams should include a full history form to be filled out to identify in advance any special problems.  Following that, every student needs BP obtained, a cardiac exam and basic check of skeletal muscular integrity.  Specific sports may require further checks, such for instance that wrestlers should not have any contagious skin diseases.
Girls usually have no further standard exams.  They do not have to take off their bra or panties for most exams.  Boys typically have genital and hernia exams done.  This is considered a standard of care by some guidelines.  The reason for this is unclear and the need for a genital and hernia exam is undocumented.  Though some information as to the child’s development can be obtained by a genital exam, the exam is usually not pertinent to the ability to play sports safely.  It is doubtful that asymptomatic hernias affect one’s ability to safely play sports.  A good history should detect who needs to be examined for this.  Indeed it is clearly recognized that the need for a genital/hernia exam is controversial.  There are no clinical outcome studies available which document the need for these exams.  In contrast, there are studies, especially in Italy, which have looked at cardiovascular screening to answer how many sudden deaths can be avoided.

These exams can be intensely embarrassing for adolescent boys.   This is widely recognized.  There’s even a small percentage of boys who refuse to participate in sports because of these exams.  I have seen women physicians blogging about how embarrassed the boys get during these exams.  Yet this problem is rarely addressed.   Reducing the embarrassment can be addressed in many ways.  For most boys, a male physician is less embarrassing than a woman.  But women who are a majority of pediatricians nowadays are often the ones who perform these exams.  As girls are fewer in numbers and not usually exposed at all for these exams it would be rational to give preference to male physicians.    Yes, modern medicine is supposed to be gender neutral, but patients, especially adolescents are not.   Increasing preference is given to female gynecologists for adolescent girls exams; the same preference should be granted to boys.

 Also crucial is the privacy which is afforded the students during the exam.  Although financially able families can take their children to private physicians, poorer students may only be able to afford school organized group physicals where privacy is routinely sacrificed.  But it doesn’t have to be.   All intimate exams should be done in private, behind screens if the exam is in the open, without any chaperones or onlookers directly watching.   Boys are embarrassed by any genital exam, but the embarrassment is intensified when there is an opposite gender chaperone watching.   That would never happen to girls; why is it considered appropriate for boys?  How would adults feel about such an exposure?  Even the military has stopped exposing young men during group physicals and now do the intimate parts one on one.  Better yet, hernia exams should only be done when the history indicates a possible problem.   The NCAA 2008-09 Sports Manual doesn’t even mention the word hernia.  There is no other need for genital exams to play sports.  If girls don’t need them, why should it have become a ritual for boys?  Embarrassing genital exams are best done during regular physicals by private physicians; there’s no need for them to be part of mass screening.  I have read many guidelines for sports physicals.  I have never seen one which gave anymore than passing lip service to privacy requirements.   I have never seen one which even mentioned the words modesty or embarrassment.

In summary, embarrassing sports physical have become almost a rite of passage.  That was perhaps better accepted in prior decades when boys were more accustomed to group nudity, generally taking group showers together in school.  But times and mores have changed.    Most kids have not been exposed to group nudity when they first try out for sports and an increasing number can’t cope with it.  Parents should be aware of this and be ready to intercede on behalf of their children.  Most are reluctant to lodge complaints with the school.  Given the total lack of evidence that routine intimate exams add to the safety of participants, the regular use of these exams should be abandoned.

Copyright © 2011 by Joel Sherman

This article has been chosen for reposting on KevinMD, a widely read medical blog.


Anonymous said...

Dr. Sherman:
Perhaps this is an over-simplified question, but how many exams have "absolute standards"? Which entity (if any)has absolute definitive authority to set such standards and then conversely, the authority to stop or change vague accepted standards?

Until standards are universal, parents need to begin considering what sorts of exams serve any valid purpose and start the process of protecting their children from needless procedures. Afterall...this is where children begin to either accept medical "authority" as absolute, or begin questioning processes that involve their bodies. (They need to know questions are healthy and normal.)
These children become the adults who surrender to tests year after year not knowing or even asking why, or they become the adults who never seek medical care because of it. Parents need to become an actual role model for their children by insisting on respectful care for them.
(Sorry for the rant.)
Truely a wonderful article that all parents should read.


Joel Sherman MD said...

Thanks for your comment swf. In fact I intended to put a sentence about parental responsibilities in the article. I have now amended it.
You're right, few physical tests have any absolute or even clearly accepted standards. Absolute standards would be a moving target needing to be constantly upgraded. Most practices are based on custom, not evidence. That is certainly true of sports physicals. Clinical outcome data is available for very little of what physicians do.

Anonymous said...

Ever see a young adult in their early
20's with scoliosis? Ever ask why it
was missed? They are headed for a life
full of medical problems all because
no one bothered to check. Hernia exams
are so much more important you see as
that was where the school nurse was.
These young adults could have recieved medical intervention with a
brace only if someone took just a
moment to do a simple check. Yet,once
they reach their late teens early 20's
at that point its too late for a brace.


Anonymous said...

Dr. Sherman,

I appreciate the article you did on sports physicals. It is sad that some boys have backed out of playing sports simply because they didn't want genital exams.

Do you know of some cases where boys refused to have genital exams and were able to play sports successfully?

I have posted a link to this article on http://patientmodesty.org/teenagers.aspx. I feel that parents often don't realize how sensitive their teenage children are about exposing their private parts to the opposite sex. I read of one girl who was in her early 20s who was very upset that her mom convinced her to go to a male doctor to check out a breast problem she had. She doesn't seem to be able to get over this.


Joel Sherman MD said...

MPM, I don't personally do sports physicals. I've seen several doctors comment that they know of kids who avoid sports because of them.
Kids who are most anxious about these exams usually have the option of seeing a private physician if they can afford it. The private physician may have the option of skipping the genital exam or doing a cursory one, such as taking a quick peek after pulling out the elastic underwear band.

Reagan said...

I'm not a lawyer, but I believe young men have every legal right to refuse the hernia exam and then demand to play sports anyway.

Given the questionable medical value of the hernia exam, I don't think government-funded schools could claim any legal right to require one gender to submit to sexually embarassing situations as a prerequisite for access to government-funded extracurricular activities.

Anonymous said...

The comment about adolescent Scoliosis was inaccurate...bracing,as the medical establishment now knows, is largely ineffective and I can say that as a girl with Scoliosis, I was exposed to numerous embarrassing full-body exams and x-rays by men. All for NOTHING as the brace did not work and I had to have surgery anyway. Too bad now I'm disabled for life..the human spine is meant to bend and having a completely fused spine is hell!

Anonymous said...

Full body exams,really. A thoracolumbar spine x-ray with
both anteroposterior and lateral projection is done standing
and is quite brief. It can be done fully clothed!

Now, if you have ever lived in the world of orthopedics
there is something called non-compliant. It's a real problem
among adolescents.


ps. Your comment does little in excusing the leering
perverts so commonly associated in boys sports

Anonymous said...

In the UK you do not need a medical to partake in any sport at school or university. You carry on doing the sport and if you feel unwell you would visit the doctor.
We have very few deaths from student sports in the UK if any!
Obviously the heart is the most prone to be a problem, never ever anything to do with the testes.

Also in the UK a doctor or patient can ask for a witness in any medical examinations. If the doctor is female and the patient male the witness must be male, and vice versa. This recognises that medicals can be embarrasing.

As for school, we do not have any medical checkups at all now.

I have two teenage daughters and they have never ever been to the doctor other than for vaccinations. If you are not ill why go? My wife and I visit maybe once every 6 years with a problem.

Anonymous said...

Excellent article! I happen to be one of those that avoided all school sports because the worthless hernia exam was performed while the school nurse watched. Both in Jr high and high school. I love sports and played on many city league and church teams, where the humiliating and unnecessary exam wasn't required. It would have been great to play school sports as well. Going to our own physician wasn't an option. My father worked in a hospital and I could have received the examination for free.

I knew I didn't have a hernia, I just wouldn't accept the exam. In my entire life I have never heard of a teenager with a hernia. They probably exist, but not to my knowledge. Certainly I've never heard of a wanna-be athlete that couldn't compete in sports because of a hernia, or any kind of problem concerning their genitals.

I'm a bit surprised but not disappointed that hemorrhoids are not checked for during sport-related physicals. I imagine they're not very common in teenagers but surely they must be more common than hernias. I guess the school representatives realize that if there was a hemorrhoid examination necessary then it would be only fair to examine girls as well as the boys, and they wouldn't want to force the girls into any humiliating examinations.

On the other topic, when I was in the fourth grade (in another State) our entire school was required to have a Scoliosis examination. Every action was taken to protect our modesty. Very few Elementary school boys feel embarrassed taking their shirts off, but we were still given very private examinations. Male doctors checked the boys and females checked the girls, one at a time in a seperated area. My sisters told me that they had to pull their shirts up above their shoulders and were checked only from the back. The girls were told in advance that they should wear appropriate clothing.

There were no problems whatsoever with the entire process. What's so difficult about that? All schools should do it. It's nothing compared to hernia exams, and both genders were treated the same.

Anonymous said...

Shame on boys who need a sports physical. Shame on
boys who just want to play sports. Shame on stupid
lawyers who make these stupid physical exam requirements aimed just at boys. And finally,shame on
any poor boy who has to visit this "family nurse



Joel Sherman MD said...

That link does work, PT. The comments are interesting and varying. I agree that I would not want to be the one seeing that NP.

Joel Sherman MD said...

I have shown PT's link to a nurse practitioner I work with, a lady I've known for years and respect. She has done physical exams for many years in varied situations, including sports physicals.
She confirmed the thrust of that article, that many men, especially adolescents, are embarrassed by genital exams and some get erections. Some teenagers are acutely distressed. She always offers a chaperone. Most refuse but some boys want their mothers there. Surprisingly she calls on a male assistant to chaperone others when wanted. She has a good sense of how to keep embarrassment to a minimum by keeping patients covered as much as possible and keeping any necessary exposure brief, literally a matter of seconds.
She's aware that a male examiner would cause less embarrassment, but has no control over it. She has to do her job.
And like the original poster, newFNP, she has very little sympathy for guys who talk about their infidelity. If guys want to discuss that, they'd be better off seeing a male provider. Reminds me of the reluctance of women to tell male physicians that they've had multiple partners as they were frequently disparaged.

Doug Capra said...

I want to comment our your interview with your NP friend. I still think it unacceptable that medicine is doing what its doing in this area the way they're doing it. Almost everyone seems uncomfortable, esp. if the young man gets an erection. Certainly the young man is uncomfortable or completely humiliated. The female NP seems uncomfortable, but she needs to do her "job," as you say. Is that what this has come down to, doing one's job? If the mother is asked to chaperone, I'm sure she's uncomfortable, too, esp. seeing how uncomfortable her son is. Even the male chaperone must be uncomfortable. Have we come to the point where we just accept that this "must" be an comfortable situation for everyone without trying to make it better? Frankly, I think that's where we are. No one's really asking any valuable questions about how we do what we do and how we can make it better. Why not ask the young men how they feel about it and what would make them more comfortable? Is it just assumed that in all cases the young man bound to be embarrassed so why bother to change anything? For some boys a male np or doctor would mitigate any embarrassment.
I also must question the whole purpose and usefulness of the genital exam if it only last seconds. What can possible be really accomplished in seconds? I recall reading an article by a dermatologist about skin diseases of the genitals. He said that few dermatologists every check the genitals fully, i.e. they don't really give a full exam. And, few of them really know how to identify the skin diseases that one finds primarily on the genitals. And one can't really diagnose them if you don't really look. Frankly, if a doctor is going to do an exam, then shouldn't the exam be complete rather than lasting seconds? How about visual observation? Isn't that as important as just feeling through clothing? The fact seems to be that everyone is uncomfortable, even the examiners, and are thus compromising the examination.
It seems like these sports physicals are situations were everyone is just going through the motions because that's the custom of how it's suppose to be -- and/or that's what it says on the insurance forms. It's just habit. We do it this way because we've always done it this way -- and we don't bother to ask any questions -- especially questions that involve allowing the patient to make decisions as to how the exam will be performed.
Can't we do better that this?

Joel Sherman MD said...

Doug, I do think that genital exams are uncomfortable with adolescents for all involved. I think the embarrassment can be mitigated, but not eliminated. This is even more true of adolescent girls who may be getting their first pelvic exam at about the same age (though it is not necessary unless there are symptoms). Boys requiring annual sports physicals though get these exams routinely and girls do not.
For all adolescents, a same gender examiner usually reduces embarrassment. Nowadays this is widely recognized and utilized for a girl's first pelvic exam, but rarely mentioned for boys. For boys the embarrassment (and potential for unwanted erections) can be minimized by keeping underwear on whenever possible and keeping exposure and exam time to a minimum. Most genital and hernia exams can be done in seconds without compromising accuracy.
As my article states, it is controversial whether hernia exams are needed for sports physicals. Any hernia large enough to cause a problem with sports would be symptomatic and a negative history should be enough to rule it out (unless the provider takes the attitude that you can't believe what the patient says). Regular annual physicals are another matter, and boys need to be taught to be self aware of any change in their testicles to screen for tumors.
I do believe that this whole topic is widely ignored, though I have no current knowledge of how today's pediatricians (who are mostly women) are trained to deal with it.

Doug Capra said...

I agree with much of what you say, Joel. But the fact that this topic is so off the radar, publicly, speaks loudly about how uncomfortable it is for everyone. Look how uncomfortable you felt even bring the subject with your female NP friend. We, as a society, are much more Puritanical than we think we are. We give lip service to being frank and honest about sexual matters -- and the media, ironically, is extremely open about this subject, in a way mostly devoid of any redeeming value. That may make us as a society think we're less uncomfortable with the subject than we really are. What surprises me, and does disappoint me, is how quiet the medical profession is about these kinds of issues. I would expect them to take the lead here. But it just goes to show how medical professionals are just human beings, too, just as much a part of the cultural mores as anyone else. Perhaps I expect too much from them.
Another aspect of this issue is an old one -- the influence of women upon men as a civilizing factor. I'm not ridiculing or discounting this. Mothers have always played an important role in socializing their boys, helping to make them men but also trying to subdue the negative aspect of that testosterone. I do believe that, with the entrance of many women into medicine, this tendency has transfered into medical culture with female doctors and nurses (and their male counterparts) assuming the role of resocializing men, esp. young boys, to accept the gender neutral world view embedded on the surface of medical culture. I say "on the surface" because that's the ideal, but it doesn't match even the cultural attitudes of many medical professionals themselves.
Just some ideas.

Anonymous said...

The thrust of the article mentions nothing about the
embarrassment of the patients, only Pervy patients
and their erections.


StayingFit said...

"And like the original poster, newFNP, she has very little sympathy for guys who talk about their infidelity. If guys want to discuss that, they'd be better off seeing a male provider."

Dr. Sherman, I find these comments to be very disturbing. Should these patients not feel free to broach such a topic with their health care provider? And, shouldn't said provider avoid judgment, and give objective advice, instead?

We are always told that we should speak openly and honestly with our doctors, so that they can give us the best medical care possible. For their part, doctors are not to judge us, nor allow their personal feelings to interfere with providing that care.

You mention that she has no patience for guys who speak of their infidelity. But, there is no mention of her reaction to female patients who also are unfaithful. And there must be some, since these men are cheating with someone!

This implies one of two things: either her female patients do not tell her of their infidelity, which is not good, from the standpoint of their medical care. Or, the women do tell her, but she does not judge them, as she judges the men, which means she practices a double standard. Neither reflects positively upon her professionalism.

Perhaps my impression is skewed, because you only mentioned your friend's comments in passing, and therefore did not fully recount what she had to say. Would you care to elaborate on her remarks?

More generally, though, newFNP, your friend, AllNurses, etc, confirm what many patients have always feared. That the medical assistants, nurses, and doctors truly are judging them, gossiping about them, and otherwise allowing their personal feelings to cloud their delivery of medical care.

Why, then, should patients not be concerned about admitting to such things as their homosexuality, to their use of recreational drugs, or to their propensity to consume bacon double-cheeseburgers? For that matter, why would patients not be embarrassed to shed their clothes for an examination?

If their health care providers are going to judge them for what they do, or how they look, or who they are, why should patients expose their vulnerabilities? It would seem that these people are not worthy of the trust necessary to do so.

Joel Sherman MD said...

StayingFit, it's hard to come up with a fully satisfactory reply. Yes doctor's should be able to treat any patient without regard to their own views and prejudices. We all have patients that we dislike for one reason or another. One tries to treat them the same no matter how one feels. Patients should not be aware of any negative feelings. That doesn't mean that the provider doesn't have them though and can't express them in private. Now a blog is not private but falls in between if patients can't be identified. Nonetheless many organizations and groups warn against blogging about patients as it's never certain that patients can't be identified. I think it is prudent to seek a doctor who you have reason to believe will be sympathetic to your concerns. Telling a woman physician all about your infidelities is not likely to satisfy that. I'd advise against it.
I intend to post a full article in several months including my conversation with a nurse practitioner.

Anonymous said...

I have had a few examinations, the last one at Scouts, and even though it was a male medical officer, I felt very embarrassed laying on an examination table naked. Andrew

StayingFit said...

Dr. Sherman, thanks for your response to my comments from May 28, 2012. I agree with you that medical professionals cannot help but have personal opinions. I contend, though, that these should never, ever be allowed to interfere with proper medical care. And, as you state (correctly, in my view), the patient should never be aware of those feelings.

While I also agree that it's best to find health care workers who are likely to sympathize with your issues, it is my opinion that this should include ALL such workers. If they focus on the affliction facing the patient, and nothing more, then any such worker should have no trouble fulfilling this role.

Besides, why should we assume that a man would be any more sympathetic to infidelity than would a woman? If not, then with whom can this man truly be honest?

Also, if, as you say, the physician should never make the patient aware of the physician's feelings, then how would the patient know that he had NOT found a sympathetic ear?

It seems to me that this places an unfair burden on the patient. He, or she, has to try to choose a physician based on criteria that is not readily knowable. Namely, how will this physician feel about me, and my choices? Not only is such information not available, it ought to be irrelevant.

I very much look forward to the article that you intend to publish, concerning your conversation with the NP. I find your articles, and these discussions, to be incredibly thought-provoking. Thanks again...

Medical Patient Modesty said...

I just learned about a blog by a doctor about hernia exams at http://more-distractible.org/2009/08/08/turn-your-head-and-cough/. It was disturbing because I feel this doctor is not sensitive enough. Hernia exams should be optional for boys. I think it is wrong to require a boy to undergo a hernia exam in order to play sports.

Medical Patient Modesty said...

I just learned about a terrible case of a male pediatrician sexually abusing some young male patients during sports physicals at http://www.leadertelegram.com/news/front_page/article_2f4f6d60-66af-11e2-b693-0019bb2963f4.html. I think it is awful that the clinic wants the case to be dismissed.

Joel Sherman MD said...

Actually according to that article Mayo Clinic wants the case against them as this doctor's employer dismissed. Doesn't mention whether there are separate cases against the physician. There almost certainly are criminal cases pending against the doctor unless the statute of limitations has run out in that state.
It's very difficult for an employer to escape liability for the actions of an employee tho. They will likely settle.

Anonymous said...

You, yourself, say that you do not do sports physicals, yet you feel qualified to speak about them. I do work with athletes. I have seen hernias in teenagers. I have seen teens with hernias that were not picked up during exams (that deferred the genital exam), who ended up with strangulations after their first week of practice or their first accidental hit to the groin. I have also had to deal with testicular cancer patients and men who were unable to have children, because they always had the genital exam deferred or poorly done due to modesty and had undescended testes, varicoceles, or hernias that have affected the development of the testes. If you feel that believing the patient that everything is normal down below is sufficient, do you believe those who are afraid of the genital exam are going to tell you anything else?

As far as erections in teens, they occur as frequently with male physicians as with female physicians. They occur in math class. How it is handled, depends on the teen. How embarrassed the teen feels depends largely on the reaction of the provider. Trying to do things quickly and inadequately or trying to keep things covered can lead to more embarrassment. A good physician should be in tune with their patient and be able to tell if there is something going on before the pants are dropped. they can take a little more time to explain what needs to be done and then ask if they are ready or do they need a few minutes.

In all cases, erections or not, I always let the teen know that they are normal. Every teen thinks that they are not normal in some way and the reassurance may ease their fears or lead to further questioning and an open discussion.

Joel Sherman MD said...

I appreciate your comment.
I am certainly not against doing genital exams, though I think they are better done as part of routine physicals rather than some sports ritual.
In any event they should be done in the least embarrassing way in private without chaperones or bystanders.
I have never commented on the frequency of erections relative to the gender of the examiner. Do you have any data on that? I have never seen any. I have only said that most adolescents find the exam more embarrassing when done by women, and there is data on patient's preferences.

Tom Wallace Lyons said...

Issues for Dr. Sherman: Could lawyers and insurance companies be the unseen hand behind hernia check humiliation? Let us look at some facts:
Granted there is doubt about the need for the hernia check. But doubt is not certainty. And lawyers might be able to exploit this uncertainty as they go into a feeding frenzy over the deep pockets of companies that insure school sports.

Here’s how it could happen? A boy gets hurt. Lawyers hire an “expert” witness whose religion is the the hernia check. Shaking with indignation, this expert screams that failure to administer the “VERY SIMPLE!” hernia check is an unforgiveable negligence responsible for the boy’s injury. How this would play before jurors with no medical education is hard to say. It is less hard to imagine the extortion of a lucrative out of court settlement.
Dr. Sherman, have you ever talked to a school district lawyer about this issue?

Another issue: Most boys will report a serious hernia. But embarrassment may cause a tiny minority to remain quiet. Could this minority become a financial time bomb if school physicians decide to drop the hernia check? TOM WALLACE LYONS

Anonymous said...

In 8th grade, 14 years old, I had to take a physical to enter High School whether participating in sports or not. The boys were all placed in the High School's Gym and told to strip down to our socks and underwear. We were lined up and after all the cursory checks, BP, pulse, respiration, etc. we were all made to drop our underwear, exposing our genitals while the doctor went down the line performing a "hernia exam" on each of us. The female school nurse followed the doctor along the line closely observing the exam and there were several school/class mothers present in the small gym who had a very close, unobstructed view of us. I, along with several other boys developed involuntary erections for some reason. This was in 1969. One young man did object but was told to get used to it, "what do you think it is going to be like when you get drafted?"
I found it de-humanizing and humiliating and obviously remember it to this day as a very negative experience.

Tom Wallace Lyons said...

Dear Anonymous, Thanks for your entry even though it is painful to read. Here is what bothers me: Sexual humiliation legitimized for medical convenience. The comment about the draft is interesting. Did decades of compulsory military service de-humanize our nation?

I have a question you might not be able to answer. Just what were “school/class” mothers doing in the gym? What is a “school/class” mother? And WHAT KIND OF MOTHER LENDS HERSELF TO THE SITUATION YOU DESCRIBE? Were you friends with any of these mothers? If so, how was your friendship affected?

I would like to think of your experience as an aberration. But medical callousness needs to be exposed. Hopefully others with similar stories will come forward. TOM WALLACE LYONS

Joel Sherman MD said...

Tom, Legal issues are in the back of the mind of any physician doing clinical medicine. So yes a physician could potentially be sued for missing a hernia that causes problems. It's not a likely scenario, but it's certainly possible. What's needed is a change in guidelines handed down by appropriate organizations. Some of them don't mention hernias, but most do.

Anon above, your experience would be rare today especially with mothers watching group physical of nude boys, but certainly that is what this post is about preventing.

StayingFit said...

Tom, I think that I can partially answer your question "WHAT KIND OF MOTHER LENDS HERSELF TO THE SITUATION YOU DESCRIBE?"

Mothers, especially in the era during which Anon's experience occurred, often viewed the bodies of their children as their domain. They cared for their own children, and perhaps their neighbors', when they were ill, and bathed them and changed their diapers.

Unfortunately, this led them to the erroneous conclusion that boys have no modesty, most especially as those boys reached puberty. Perhaps they knew better, but did not want to admit it. To do so would mean that they would have to surrender their "domain". It would also force them to acknowledge that their children were growing up, which can be difficult for a parent to face.

Of course, their is some sexism involved here, as well, since these same mothers would never tolerate such treatment of their daughters. Perhaps because they could empathize with the girls, but not the boys. Or, perhaps because these mothers felt that it was the domain of all females to provide intimate care for everyone, but males could not. To treat their daughters as these boys were treated would be unthinkable to them, especially as the girls reached puberty.

Whatever the cause, I think that Dr. Sherman is right in that such a situation would be rare today. I wish that I could say that it's because society now recognizes that boys do care about their modesty, but I don't think that this is true. Just have a look at the posts on the various threads on this blog, to see the truth of that.

Instead, I think it's because of the very legal issues that you mentioned in an earlier comment. School systems, for convenience and cost, and some mothers, due to their erroneous assumptions, might very well conduct exams in this manner today, if permitted to do so. However, the lawyers, as well as a few enlightened parents, would never stand for it. The risk of legal action is just too great. And, for once, I'm glad of that!

Tom Wallace Lyons said...

Response to StayingFit from Tom Wallace Lyons:

Thanks for your Sept 2nd. comments about my August 21st post. Let me start with the "sexism" you discuss in the third paragraph.

At seventy I remember the days when pregnancy more or less destined women to bear and intimately care for their children and other children. To ensure that progeny issued from the husband, a woman's honor was predicated upon pre-marital virginity. Granted I generalize. But men tended to be the dominant sex. Hence the occasional inclination to treat intimate female anatomy with a reserve not accorded the scepter of male superiority.

But it gets complicated. I use the above term "occasional" because I believe that for boys the assumption of genital privacy from females was an unacknowledged rite of passage which helped define that all important separation of the boys from the men; a separation of profound emotional significance evidenced by the fact that the word "boy" is a vicious tool of racial insult when applied by a white man to a black man. Thus genital privacy kicked in either before or by the time a boy was perceived to have attained the outer precincts of adult sexual viability.

I believe women of my youth had an instinctive understanding of how boys needed to be treated. However this understanding was weakened by the fact that it was never underwritten by clear concept.
Maybe that is why Anon's "school/class mothers" did not realize the hurt to the boys' pride in their emergent manhood. Maybe that is why they did not leave the gym.

I have read other posts like Anon's Like Anon the writers often describe feelings of violation. They generally seem to perceive their experiences to be outside the norm. Hence my perception and hope that Anon's situation was unusual. But I have to admit that bodily privacy between genders may be an issue around which there is little consensus.
My grasp of the issue is more intuitive than empirical. The issue seems to be emotionally fraught and poorly understood. Tom Wallace Lyons

Joel Sherman MD said...

Here is a semi official sports physical exam form from 2010 as recommended by many societies including the American Academy of Pediatrics and the American Academy of Family Practice. Also included is the American College for Sports Medicine and the American Medical Society for Sports Medicine. In other words it is an all inclusive consensus document.
Of interest is that the genital exam is included for men only but there is a footnote stating "Consider GU exam if in private setting. Having third party present is recommended."
In other words the GU exam is considered optional but recommended. The recommendation for a chaperone clearly reflects legal concerns.
Making the exam optional is an improvement though it would be better if it stated that it should be part of an private annual doctor's visit.

Anonymous said...

The complete American Academy of Pediatrics Policy Statement Use of Chaperones During the Physical Examination of the Pediatric Patient:


"In general, it is wise for male clinicians to have a chaperone during female breast, anorectal, and genital examinations. However, even same-sex examinations can be misunderstood and can benefit from chaperoning. The patient's wishes and comfort should determine the sex of the chaperone. If the patient chooses to have a chaperone, the chaperone should preferably be a nurse or medical assistant."

The AAP Chaperone Policy statement, published 25 April 2011, seems to contradict the 2010 sports physical exam. I wonder if they're aware of that.

In 2011, "The USPSTF specifically recommends against screening for testicular cancer in adolescent or adult males."

The USPSTF makes no recommendation, for or against, routine screening of males for hernias that I could find.

Why is the medical community so obsessed with adolescent male genital exams in the absence of verifiable data supporting such intrusive exams?


Joel Sherman MD said...

Thanks for reminding me of that reference, Ed. I note that it was published well after my original article on chaperones and I hope that my article had something to do with it. My article was not referenced, they would be reluctant to reference an article from a blog in a full medical journal, but it is likely that they would have seen it if they fully researched the topic.

Anonymous said...

It is disconcerting how little information can be found in terms of what constitutes an appropriate genital exam of a boy or teen so that as parents we can pre-educate our children what to expect and more importantly what to prevent.

I was 13 when my doctor gave me my first male genital exam (I am 40 now but as was the norm then no other person was in the exam room save myself and the doctor).

His nurse instructed me to undress to my underwear and to wait for the doctor. When he finally came in he immediately asked me to "drop my britches" and proceeded to use both hands to briskly massage my genitals causing significant pain. I remember being completely shocked and it seemed like it went on forever before he said I could pull up my umderwear. He then had me lay down and put his hand down my underwear and touched my penis.

Afterwards I remember trying to tell my mother what happened but she stopped me saying it was okay and that all boys have to go through that type of exam. To be clear, she was a great mother and simply had no idea what had happened and was just trying to save me embarrassment.

I apologize for being graphic, but I left that room thinking something bad had happened but I had no independent way of knowing if what he did was accepted medicine or if it was what I believe it to be now: molestation.

He has since died but until this day it haunts like me and I never have let my sons be alone with a doctor.

Joel Sherman MD said...

Anon, from your comment it is hard to tell if the physician did anything overtly wrong. Your mother may have been right.
But he clearly did not take the time to explain to a frightened kid what the exam consisted of. He should have.

Anonymous said...

Come on Dr Sherman, no male genital exam consists of brisk massage causing significant pain. A hernia check might be uncomfortable but certainly not painful. Additionally, why would a physician place his hands into a boys underwear after completing the genital exam. I think it's obvious the physician did everything wrong.


Anonymous said...

Absent any trusted third party guidelines, it is difficult to judge whether he was clinically correct in his examination. It was just a normal yearly exam in advance of school. I've never had a doctor since touch and rub my genitals like he did (rubbing, caressing, struggling to describe how he used both hands to in effect feel me up as much as possible). It went on for several minutes and he was rubbing me hard enough that it became very painful. He never explained what he was doing or why. He never asked me to cough or do to anything remotely like routine genital exams I've had as an adult. It was conducted in a standing position with him facing me.

Maybe a good way to protect patients and doctors is for the doctor to provide a written a written guide for parents and kids exactly what he or she will be doing so as to prevent the potential for abuse as well as for false allegations. At least then parents and kids would have the info to know whether or not the exam was appropriate. Thanks again for your reply. Much appreciated.

Joel Sherman MD said...

Anon, your further description makes it clear the exam was inappropriate to say the least.
Ed, it is common for docs to do a genital exam with the underwear on. In older kids and adults one is mainly feeling for masses and direct vision is of lesser importance. But I agree that if this happened after an initial exam it served no medical purpose.

Anonymous said...

Thanks again. My goal in posting wasn't so much to validate that what to me was wrong (it was), rather to try and help move forward a discourse that addresses how best to protect patients and doctors. Clearly genital exams are essential (to what degree, I can't say as I am not a physician) but what is clear is that there is no readily available material that states specifically how such exams are to be generally performed. In fairness to doctors, I do understand that the art of diagnosis isn't always an exact science. Certainly, I can understand if a doctor detects a mass in the genitals that he or she needs enough leeway to examine further and perhaps in doing so necessarily must be more invasive. In that regard, maybe best practices would require the physician to inform both the patient and parent of the need to examine the genitals more thoroughly. That said, we need to better educate kids what to expect. I didn't know and had no way of independently finding out if what happened was inappropriate. I was just shocked and at no point was aroused whatsoever. For years, I wondered if maybe this was the norm but once into my 20s I finally was able to accept that my initial gut reaction that it was wrong was indeed the case. Again, my goal in commenting is to help prevent kids from going through what I did and all of the doubts that followed. Likewise, I believe it is important to protect doctors as well from false accusations. Thanks again to all.

Anonymous said...

In fairness to this doctor, I did have two abdominal hernia surgeries when I was 5 and 7 (left&right) but had no trouble whatsoever since those surgeries nor when I was being examined had I raised that I was having pain prior to seeing him. The only pain was that which he caused and I was too shocked to object or say anything. Again though, my larger point is raising how best to inform kids and parents today than I was then. Thanks.

Anonymous said...

I realize I went afield of this thread. With respect to embarrassing, I can't see any reason why a medical exam would occur in mass and in a public setting. I grew up as an expatriate in Germany (although all of my doctor exams were in the US during summer home leaves) and public nudity was and is widely accepted so from my earliest memories I always was conscious of seeing naked people of all ages on TV, billboard advertising, parks, and beaches. By no means we were nudists, but am pointing out how public nudity is the norm to emphasize my opinion has nothing to do with modesty of being seen by adults or kids of both sexes, rather that anything wherein an examination of genitalia whether adult or child has no place in public. It seems to violate every aspect of what we believe to be a strict doctor patient confidentiality. I also believe it is inappropriate for schools to conduct mass exams on campus. I realize in some areas it may be an economic issue, but there needs to be clear dividing lines between schools and exam rooms and school staff should not take part whatsoever in exams of students (including school nurses).

Unknown said...

I've heard plenty of stories about how embarrassing it can be for guys to get sports physicals. It surprises me that there are more female doctors that perform the physical than there are men who do. I would think that an effort would be made to switch it more towards males performing it so that it would be less awkward for the patients.
Keara Littner | http://www.picmc.com/immediate.html

Joel Sherman MD said...

Keara, if you are associated with a clinic that performs sports physicals, please tell us what accommodations your clinic offers (or doesn't) to kids to avoid embarrassment. Would they have a choice of what gender doctor they can see?

Doug Capra said...

I, too, would like more information from you about what Joel asked. I checked out your website and it looks like you have a decent balance of male and female staff. Seems no reason why your office couldn't accommodate males to give them more privacy with a same gender examiner, if they so desired.

Unknown said...

Anything that is required is coercive, therefore should be minimally invasive or non-invasive. This is not just about modesty, this is about peoples fundamental rights.

Such as the right to consent or refuse, the right of privacy and dignity.

Some have said that in sports there is no expectation of privacy to begin with, but it is consensual, and even in the locker room, you don't have a fully dressed adult man or woman in there scrutinizing and handling kids genitals or sticking a finger up their bums.

ALSO, there is this. The massive contradiction between telling our children to not allow strangers to mess with them, UNLESS they are authority figures, THEN, you are to totally submit to authority naked, and do whatever authority says while you're naked.

As Americans we should resist automatic and absolute submission to authority, including doctors. Look at how many doctors that have abused their authority, and the police, too. And teachers, and school principals.

Sex predators are attracted to occupations that put them in close proximity to kids.

No system is perfect, there are going to be mistakes no matter what, so we as Americans should error on the side of liberty, and everything that is associated with that.

We must stop erroring on the side of safety or security, because if we put the illusion of safety or security above all, we end up losing all. Including our dignity.

Therefore, unless there are symptoms or behavior that would warrant invasive procedures, then you keep away from my children's private parts. Thank you.

Do we live in America or North Korea?
This goes way beyond simple modesty issues.

Ditto, drug testing. In this country there is supposed to be the presumption of innocence, not guilt, but today everybody has to prove that they're not guilty of something.

"YOU PROVE YOU ARE NOT GUILTY OR ELSE!" Or else you don't get the job, or you get fired, or you will be arrested. And then when there is a false positive with your urine test, ENTER DIRECTLY OBSERVED COLLECTION.


This is completely backward, and we are all being treated like prisoners as a result. This is not America, and I hold the medical establishment partly responsible for this, because it is cooperating with the tyranny, instead of resisting it.

For many years the medical establishment has been conditioning us from childhood to completely submit to any and all authority.

Remember what happened at that famous restaurant chain when some prankster on the phone called. Everybody just unquestioningly obeyed, and an innocent employee ended up raped.

Watch Compliance (2012).

We have to replace the security state with the restoration of liberty. Liberty IS the security. You trade liberty for security, you end up with neither. The whole establishment will victimize you on a routine basis. You won't have to worry about what bad guys will do to you.

Let our children play sports without making them feel that they are the property of the state, and have no rights, including no private parts.

And when our young athletes win, they can be taken aside by an authority figure, walk with them somewhere secluded, then ordered to expose themselves and pee in a cup to prove that they didn't use performance enhancing drugs.


"Land of the free, and the home of the brave."
Are we as Americans brave enough to be free?

Anonymous said...

I completely agree with the author. Every word in this article is correct. The necessity of performing hernia exams could be discussed; but one thing I know for sure: boys have a right for privacy during medical exams EXACTLY (!) as girls have.