Sunday, September 30, 2012

Adolescent Boys and Genital Exams
Reducing Embarrassment

              by Joel Sherman MD

Here is an unusual post that actually discusses the most embarrassing part of the male physical exam.  Every practitioner who does male genital exams is certainly aware of this problem yet it is rarely discussed.  I quote from this anonymous nurse practitioner's (NP) blog:

It is a hard fact of practice that there will be a time in a clinician's life when he or she will be confronted with an erect penis.  … In newFNP's experience, these awkward moments tend to occur with teenage boys who will pitch a tent upon sensing a sideways glance at the penis. … In general, newFNP really feels sorry for her male patients who have an itchy trigger penis. She knows that they know that they have an erection at an inappropriate time. She knows that they are uncomfortable and assumes that they might like to sink into a crack in the floor. 

I showed this blog to a NP I know who does sports physicals.  She confirmed all the main points:  Yes, this occasionally happens and the boys are generally incredibly embarrassed.  This has been posted about a few times by other practitioners as well although the articles have since been deleted.  I asked the NP whether she was trained to deal with this situation.  The answer was no, the subject was never mentioned in her NP training.  My medical training was decades ago, and that was certainly true then; the subject was never mentioned.  I tried to find out if it is any different now.  A medical educator and physical exam instructor of 2nd year medical students, Dr. Maurice Bernstein  says that his students are told to reassure men that it is a normal physiologic reaction.  It’s hard to know what else to say, but the response can beg the question.  It is a normal reaction for the practitioner.  -But not for the patient.  Adolescents are not used to having their genitals seen and touched, especially in a non sexual situation, and may respond sexually.  Despite reassurances to the contrary, as seen in the above quote from the blog, the encounter can be a source of amusement to others.    

Standard textbooks on adolescents and physical exams have almost nothing to say about this.  Mosby’s Guide to Physical Examination (4th edition) was the only text I came across that actually mentioned that young patients especially may be fearful of having erections.  But it doesn’t make any recommendations as to how to avoid the problem or what to do when it occurs.  Two textbooks (Swartz, Textbook of Physical Diagnosis  (6th ed.) and Bickley, Guide to Physical Examination, (10th ed.) had brief articles on how to reassure girls for their first pelvic exams.  Incredibly though when it came to the male genital exam, these 2 books only discussed how to reassure the medical student doing them.  The patient’s embarrassment was not mentioned.  Yes the exams are embarrassing for new physicians as well, but concern for the patient should remain primary. Two texts I viewed on adolescents said nothing about the subject.

So it is well recognized by practitioners that genital exams are embarrassing for boys as well as for girls. It is also documented that the gender of the provider is one factor.   (Adolescent Girls and Boys Preferences for Provider Gender & Confidentiality in Their Health Care, Journal of Adolescent Medicine 1999;25:131-142. &  Patient Preferences for Physician Gender in the Male Genital/Rectal Exam, Family Practice Research Journal, Vol 10 No 2, 1990.)   There is evidence for both boys and girls that the exams are more embarrassing when done by opposite gender providers (for further references see link).    The American Academy of Pediatrics (AAP) has published extensive guidelines for both male and female genital exams.  For girls it states: Clinicians should always be sensitive to the possibility of past or current sexual abuse, which can affect the patient's comfort with the examination and her preference regarding the gender of the examiner.  For boys it states:  Trust and relationship-building are also critical elements of the male adolescent's visit that help him to feel comfortable regardless of a physician's gender and/or background.  In other words for girls one should respect their gender preferences for the exam.  For boys it makes no difference if the exam is done properly.  And they don’t appear to recognize that sexual abuse of boys is very common as well, about half the incidence of girls.  The conclusion from the AAP appears to be that girls should be given a gender preference and boys should not.  Given the clear embarrassment that both boys and girls can suffer, there is no justification for the different treatment.  

Likely this difference is a reflection of the varying importance Western society has put on modesty for women vs. men.   And it probably also reflects the genuine difference in the complexity of the exams, a woman’s gynecologic exam taking up to 15-20 minutes with specialized equipment and the patient in an unfamiliar embarrassing position vs. a few minutes for the average male exam with no unusual equipment or positions needed.   But clearly the embarrassment that boys feel during these exams can be comparable to what girls go thru, especially if an erection develops.  Indeed many men as well as adolescents can’t help but feel that someone handling their genitals is a sexual experience, usually more intense with an opposite gender provider.

Adolescents in particular deserve utmost sensitivity for genital exams, especially for their first thorough one.  While this is recognized for girls, it is rarely mentioned for boys even though every practitioner must be aware of boys’ embarrassment.  Parents will often accede to their daughters wishes for gender preference and will prepare their daughters for what to expect; boys are rarely accorded the same consideration which is now much more of a problem than it was years ago when female pediatricians were a small minority.  It is easy to find texts and manuals as to how to handle pelvic exams in the least stressful and embarrassing way possible.  For boys a similar discussion is rare.   Most practitioners must know how to reduce embarrassment by keeping the boys covered as much as possible and keeping tactile stimulation to a minimum through brief exams and the use of gloves.  It is time that medical teaching and parents caught up with the fact both boys and girls need equal consideration including offering them a preference for the gender for the provider.