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.

59 comments:

Doug Capra said...

Good article, Joel. Try to post this on KevinMD. You should also send this to the professional organizations you mention in the article. They need to read this

Joel Sherman MD said...

This comment was sent by Dr Maurice Bernstein:

Based on my years of practice as a male internist examining primarily adults, the patient's development of an erection during the exam is very, very rare. I have never, nor are the second year medical students taught to inform the patient prior to a genitalia exam that a penile erection might occur and if this does occur that this can be a normal reaction and is indication that the blood supply and nerves are normal.

I would be interested to read from the visitors her whether patients, particularly adolescents, should be told before the genital exam that such an erection is possible or whether this information might provide further anxiety about the procedure. ..Maurice.

Joel Sherman MD said...

Maurice, erections would be rare as you note when a male provider does genital exams on adult men. I think the situation is very different when a woman provider does exams on adolescent boys. An embarrassing situation is much more likely to occur then, though still not frequent.

I personally wouldn't think the situation would be helped much by explaining to kids beforehand the possibility of an erection; might indeed make it worse. It could be helped by making sure that the kid is comfortable with the doctor he's going to be seeing, i.e. that he has a choice in the matter including the gender of the provider. He should understand that a genital exam will be done.
Admittedly as a cardiologist I have little professional experience with these situations.

Anonymous said...

Thanks for your excellent article Joel. You have shed light on an important topic that is generally ignored. As I read your piece I could feel myself becoming more and more angry that many young boys are exposed to these exams every day.

While most of us would agree that parents have the right to exert authority over their children and ensure that they receive proper medical care, there are legal limits to parental authority. We know that if parents forcefully strike a child and inflict serious injury they may well lose custody of that child. However, if a parent forces, against his will, a modest adolescent boy to undergo an intimate physical exam by a female practitioner, society appears to believe that this is acceptable even though the argument can be made that such an exam is a form of sexual abuse.

An obvious question is why should females be involved in intimate exams of boys at all unless the young males has been fully informed beforehand of their right to refuse such an exam and given the choice of seeing of seeing a male practitioner? I know this might at times require more effort or time on behalf of the medical staff but if they truly care about their young patients shouldn’t this be done.

I would like to see responses from female physicians, nurse practitioners, and PA’s explaining why they are willing to take part in these exams. An obvious answer, of course, is that it is to protect the adolescent’s physical health. But we know that mental health can be just as important as physical health and the embarrassment and humiliation that many modest adolescent boys experience in these exams can be psychologically damaging and may well be a prime reason why later in life adult males on the whole are much more reluctant to visit a doctor that adult females.

If a female practitioner believes that it truly is acceptable for her to conduct intimate exams such as these, I believe she has a moral and professional obligation to explain to boys, many of whom are as yet quite naïve about their rights regarding medical treatment, exactly what will take place during the exam and to clearly inform the patient that he has an absolute right to refuse any part of the exam without being coerced or ridiculed into accepting whatever the practitioner decides should be done. If a modest boy refuses the intimate portion of an exam, I believe a caring female practitioner could certainly offer some advice to assist the adolescent in finding a male practitioner with whom he might be more comfortable.

Finally, I would urge all parents to talk with their children and determine if they have have a gender preference regarding who performs their physical exams and if they do, that preference should be respected.

Anonymous said...

As a parent of boys and girls, I have never and will never allow my children's genitals to be examined by anyone unless they have symptoms. If an exam of this type was needed because of symptoms, they would certainly only be seen by a same gender provider. I find the routine intimate handling of emotionally/psychologically fragile young people to be extremely disturbing. In my mind there can be no justification for it. Lkt

Anonymous said...

Great article. As parents, we made sure the physicians gender was the same as our kids. Additionally, as they entered puberty, we never added to their embarrassment by remaining in the exam room.

I sent a link to this article to my 18 year old son (freshman in college away from home) with the following message:

"While you're an adult, you're also still a teenager and this might not concern you at all. If it doesn't great; if it does, remember you have the ethical and legal right to chose who and what degree someone (physician, nurse, student, chaperon, observer, etc.) participates in your healthcare."

Dr Sherman, can you help publicize the patient modesty petition that Dr Bernstein started. Follow this link if your interested; http://www.thepetitionsite.com/799/493/745/medical-care-providers-must-attend-to-patient-modesty-issues-and-provider-gender-requests/

Many thanks for your continued advocacy on these issues!

Ed

Medical Patient Modesty said...

Thank you for this great article! Medical professionals need to work on being more sensitive to teenage boys' needs for patient modesty. The truth is many genital exams are actually unnecessary. Teenage boys should always be given the option of having a male doctor or nurse for necessary genital exams.

You should certainly send this article to professional organizations.

One of the goals of Medical Patient Modesty is to have some seminars at schools educating parents about how to be sensitive to their teenagers' needs for modesty in medical settings eventually.

Anonymous said...

"I would be interested to read from the visitors her whether patients, particularly adolescents, should be told before the genital exam that such an erection is possible or whether this information might provide further anxiety about the procedure."

Why would a provider specifically address what the patient is already worried about, especially if the provider is female? Seems to me comments like this would make the patient more uncomfortable. While I can't speak for others, at that age, erections occurred at the most inopportune times for seemingly no reason at all; certainly not for any sexual thought or stimuli. I can remember walking between classes in junior high with my books strategically held, or shopping with my Mom and my hands crammed in my pockets, both attempts to hide the evidence.

Now if an erection actually did occur during a physical, certainly the provider should acknowledge it by commenting to the effect that there is nothing to be ashamed about, at your age you don't have any control over it, and it's a perfectly normal and healthy reaction.

Ed

Doug Capra said...

Ed --

In my view, that isn't the point. The point is, patients should be asked about their gender choice when exams like this will happen. To your point, yes -- this information might make some patients more uncomfortable, others not. If it's asked, it should be immediately followed by the gender choice question. As to the "perfectly normal" cliche. The reaction may be normal -- but the context and situation in which it is happening, especially if the provider is of the opposite gender, is not a normal situation, and to pretend it is normal is to just hide behind reality.
This also gets to the point as to who decides whether patients should be told the truth or whether the caregivers should decide who gets the truth and who doesn't. When the patient is not told the truth, and then the truth is suddenly revealed -- the reaction is often one of being ambushed and/or lied to. Sometimes it's a difficult situation for the caregiver. But, generally speaking, the default position should always be the truth.

Anonymous said...

Go to allnurses.com, same subj and read the comments. While I agree patients should be given a choice, the reality is we are discussing minors and they don't make these appointments, their parents do. In a perfect world, this wouldn't be an issue for either gender, but its not so saying it should be is a moot point.

My comment about being uncomfortable is obviously my opinion alone and recognize others may disagree.

While I'm not defending providers, you essentially require them to be mind readers in anticipating the preferences of their patients; that's an untenable position to be in.

And what one individual considers abnormal, others will be perfectly fine with what you say "is not a normal situation."

Finally, I don't have a clue what your point is with respect to the truth or why you're raising the issue in conjunction with my comments.

Ed

Anonymous said...

There is no justification for the routine examination of
genitals. I see it as simply a power trip for these female
np's as well as bringing another female nurse or ma
into the exam room.
Ask many a 21 year old with scoliosis who had a
physical at 15 or 16 and ask them why it was missed
by the np or pa. Why is it so important for a genital
exam? There are many disease processes that can
plague young adolescents. Routine genital exams are
a redundant practice and should be questioned by all
parents.
Ask these female np's when the last time they had
a mammogram by a male tech and why they don't ask
for a male tech on their next mammo appointment. Let's
just see how deep their hypocrisy runs.

PT

Anonymous said...

Doug, I was answering Dr Bernstein's question and while they should be asked, the reality is their not. Obviously, what's comfortable for some will not be for others; I stated my opinion. We're talking adolescent boys who may or may not have an input into scheduling their physical exams. The myriad of ways (summer camp, boarding school, athletic team, ER visit, parent, etc.) this is done is beyond the scope of Dr Sherman's article. And while we agree all should be asked if they have a gender preference, certainly you must agree that is an ideal that will likely never be realized.

Boys will continue to have their physical administered by female providers. Some boys will find it perfectly normal for a female provider to administer their physical exam and be completely comfortable with it; most will not.

Unfortunately, through no fault of their own or the provider, some will experience an erection and corresponding embarrassment. How can you characterize this a "normal situation" vice abnormal based solely on the providers gender? Many will be more embarrassed because of a female provider, others equally embarrassed, and others more so due to a male provider. Regardless of gender, a provider should acknowledge an erection by reassuring the patient that "this happens all the time (it doesn't but he doesn't know that), it's a perfectly normal and healthy involuntary reaction (it is), and nothing for you to be embarrassed or ashamed about" (absolutely true). Simply ignoring the erection and offering no reassurance likely will lead to mental anguish (there must be something wrong with me, I'm a freak, etc.) and avoidance of future medical care fearing repeat occurrences; my opinion.

Ed

Anonymous said...

Ed

Not to hijack your thread, but I would like to make
some comments. Who is it that is saying some boys or
all boys are getting an erection during these exams. Is
there some empirical evidence or is it just propaganda
from the female dominated healthcare machine. Many
female providers ( np, Rn and cna) make the comments
that old men are always flashing them. That all boys and men are getting an erection from their presence must be flattering that every male they encounter is
just dumbfounded by the provider's beauty that they
all get an erection.
Don't believe it for one minute. It is their way of
looking innocent in a long held discriminatory process.

PT

Anonymous said...

PT its not my thread; I was trying to address Dr Bernstein's question from 1 Oct. They certainly occur I assume because providers say they do; although much less common than the average adolescent fears. I actually wouldn't know because it never happened to me but I admit to worrying about the possibility during my physicals as a teenager. And regardless of the frequency, if your that boy I think a provider regardless of gender better be able to deal with it forthrightly and professionally; ignoring it may be partially harmful, IMO.

Ed

Anonymous said...

I intended to type potentially instead of partially in my 10 Oct post; clarification only.

Ed

Anonymous said...

"I would be interested to read from the visitors her whether patients, particularly adolescents, should be told before the genital exam that such an erection is possible or whether this information might provide further anxiety about the procedure. .."

It seems to me that if we are not talking about it, then we are hiding it. If anyone already has "anxiety about the procedure" and we don't allow room for all information, then that is a sort of "deal with it later instead of now" ambush. And isn't that part of the problem? People/children/adolescents not being given all of the information that they may need?

At the very least, parents should say that the exam may likely include members of the opposite gender, and how does the child feel about that. That gives the child opportunity to discuss the "what if's", and parents the chance to possibly mitigate the problem.


suzy

Anonymous said...

Adolescent boys are well aware "unprovoked" erections occur for seemingly no reason at the most inopportune time; my opinion based upon personal experience. I don't believe a provider, especially female, needs to broach the subject when its not yet an issue. The boy is already worried about the possibility and I'm not sure what is gained by the provider discussing it beforehand, IMO.

I agree that parents at a minimum, should discuss the possibility of the opposite gender, well prior to scheduling the exam, and honor the adolescents preference. That discussion should also frankly discuss what the exam entails, what appropriate touching is, in the case of boys, the possibility of an erection occurring, and whether they desired either Mom or Dad to remain in the exam room for the duration. They should be afforded the opportunity for a private discussion with the provider (absent parent) so they may discuss any issues their uncomfortable discussing with Mom/Dad. This wasn't nearly the issue with our daughter because she didn't receive a pelvic exam until quite late in her teens; her preference was a female provider. Since genital exams of boys seem to be mandatory (explain that) we had this discussion with our son as he entered puberty prior to his first sports physical; he preferred a male provider. We honored our children's preference.

Ed

Anonymous said...

Allnurses.com shut down the thread on this same subj. They can post condescending and patronizing comments but the patient and paying customer cannot respond in kind. I can only assume many (not all) enjoy the status quo and the corresponding embarrassment we suffer. Additionally, they perceive this issue as a threat to job security. I recognize its not fair but it reinforces my negative perception of female nurses.

Ed

Joel Sherman MD said...

Ed, I have been on vacation with limited access to the web. Didn't see the allnurses comments. Was there a pattern to them?
Allnurses has never been friendly to outsiders and routinely deletes threads they don't like. I have not found it useful to post there.

Anonymous said...

Yes there was a pattern. They decided how other people
should care for their children.

PT

Joel Sherman MD said...

I've been asked to post the following by Lars Petersson, a contributor to this blog.

Thanks again to Joel for bringing up this very important question. It is important because this very problem is, no doubt, one of the main matters which keep young men away from doctors and health care - all this with serious consequences to their health, ultimately to their lives. Germany with a history of extremely humiliating genital examinations of conscripts (and male army personnel) to the armed forces is in top of the league for fatal testicular cancer in the western world. Why, because few will never try that treatment again. http://www.larsgpetersson.com/military-abuse/in-english-2/ In England where I live and where I used to be a nurse and my wife still is a NP I am happy to claim protection of patients' modesty is high priority.

One suggestion for all examinations of male genitals: let the patient prepare himself behind a curtain in private; ask him to lay on the couch with the trousers only slightly pulled down, or as much as necessary. Perform whatever needs to be performed with the patient on his back or laying down (any erection would be much less noticed and embarrassing). After the procedure is over, leave and let the patient put back his cloth on his own still protected behind the curtain. This is the way this would normally be conducted in a British surgery. The patient 'invites' the practitioner to come in behind the curtain and perform what is in his own interest; after all, he is the customer.

One bad egg exists however. In a TV program called 'Embarrassing bodies' (shame on them) a female British GP make all this into sex. http://www.dailymotion.com/video/xlo1iw_lady-doctor-performs-testicle-exam_lifestyle I am planning to take action against this video. It keep young men and boys away from the doctor and threaten their health. Please join me in this action. Will come soon on my website. She has to be stopped as this video is easily found if somebody type 'testicles, exam and video' - what most people wanting to know more about this would do.

Lars G Petersson

Joel Sherman MD said...

Thanks Lars.
But I must admit that I have little problem with the video you mention. It's intent is clearly educational and the patient is presumably a volunteer who is not embarrassed.
I'd only comment that it would be preferable to show these exams while the patient is partially covered as they are more usually done. Showing a guy standing there fully exposed could scare off some people.

Angus said...

When I was young, aged 11 and just beginning puberty I was in a car accident bad enough to leave me in the hospital for a full five weeks. During that time I got bed baths almost daily from several nurses, often developing an erection. Most ignored them, but at last two of them reassured me that it was normal. That was crucial to my acceptance and growth from the experience. It happened so frequently I became used to it and progressed from finding it embarrassing to actually liking it, at least somewhat, even though I remained partly embarrassed. Remember I was only 11, and knew almost nothing about sex.

Years later I realized that every time, or almost every time, I had a procedure or exam done by a woman I would get an erection. It was totally involuntary and has lasted more or less without exception throughout my life. I am now 58.

Because of these experiences I consider myself something of an expert on the variety of medical women's reactions to men, or at least me, getting an erection. The reactions range from ignoring the erection to saying it is normal to actually complimenting me on it to outright amusement.

And of course I also know my own reactions to their reactions. From that I have concluded that the best way for a woman to respond to a teenager, or a male of any other age who gets an erection is 1) preferably to say that it is normal and healthy, or 2) to compliment the patient on his erection and (implied) health.

The worst way to respond to a young man or a teen is to laugh, criticize or seem amused by it. I think that is obvious. But ignoring it is almost as bad, because in fact such a reaction is duplicitous at best and outright lying on its face at worst.

I offer all of this because I have, as I have said, substantial experience with the matter now and have given it some thought.

The key ingredient of whatever a female medical person does in these situation is to give reassurance, especially if the patient is a teen or older boy.

Joel Sherman MD said...

Angus said:
That was crucial to my acceptance and growth from the experience. It happened so frequently I became used to it and progressed from finding it embarrassing to actually liking it, at least somewhat, even though I remained partly embarrassed.

You can get used to anything Angus. If male personnel got a girl excited no one would find that acceptable. The experience you quote is often the beginning of sexual fetishes and nothing that should be encouraged in my opinion. The nurses and personnel clearly knew what they were doing day after day.

Anonymous said...

Dr Sherman, based upon the information Angus related, I think your comments were overly harsh and judgmental.

He was 11 years old, in the hospital for five weeks, and what he related was certainly not inappropriate on his or the nurses part.

Maybe I'm missing something here but I perfectly understand how those experiences as an 11 year old led to his involuntary erections throughout his life.

Additionally, while there may be an element of a sexual fetish here, it's certainly not his fault nor did the nurses act inappropriately in creating it. He certainly hasn't related any inappropriate actions on his part subsequently in later years.

Based upon the information provided, how did he or the nurses encourage anything and while the nurses "clearly knew what they were doing," how is that inappropriate?

I think you owe Angus an apology.

Angus thanks for the frank and forthright discussion of your experiences.

Ed


Angus said...

The reason I offered my experience and my suggestion is that I took the purpose of the article to be what should and what can be done when a young man's genitals are to be examined. In particular what should be done if they examiner is a woman and he gets an erection.

Although I have nothing against the idea of allowing a youngster to pick the gender of the examiner, that seems to me to be a highly limited option, for a couple of reasons. First, the boy might not fully realize what is going to happen and/or not know which choice is better for him. For instance, he might in his past experience find women practitioners more reassuring in general, or he may even be fearful of some fanciful homosexual implications of a male provider. But, much more to the point, there may well be no practical way for a choice of genders to be given, since so many exams are done by NPs these days, most of whom are female. Also more that half of new doctors these days are women. I know in the clinical/HMO practice I belong to, fully 75% of the new MDs are women, and there are more women among PCPs than men.

So to my mind, the question becomes how do you train these women to respond in such situations where a male patient gets an erection.

And my answer is 1) don't just ignore it, and 2) say something positive, ideally in a medical way, about it. Thus, "I see you are a healthy young man".

As I said in my first post, I have had enough of these encounters to have become something of an expert at them. One thing I have learned is that some women are quite good at saying things like I suggested, doing so in a matter-of-fact way, and then getting on with their job. I believe people when they say erections do not happen very often in such situations, but when they do it seems to me it is in the patients' best interest for the woman to respond as I just suggested.

Joel Sherman MD said...

Ed and Angus, many thoughts:
First I appreciated the reason given as to why Angus posted, giving his thoughts on the appropriate responses of practitioners to the development of an erection.
Ed, only Angus knows whether he has a fetish, but he implies that he gets erections frequently during exams. This is certainly not common and fits the definition of a fetish, i.e. an unusual or abnormal trigger for sexual arousal. Fetishes are very frequent, purportedly the majority of men have them and many women. There is nothing criminal or perverted about them necessarily. For most people they are quite benign. But they're not particularly desirable either. A common reason for their development is a childhood incident just such as Angus describes. No the nurses didn't do anything wrong in their own estimation, but it should have been handled differently. Be less likely to happen today, though it probably still does happen. No medical professional would want to purposely cause sexual arousal in a patient; most go out of their way to avoid it. But there are nurses and doctors who are amused or aroused by it. If a male did it to a girl, he could be accused of assault, but nurses can get away with it.
But my article has the emphasis on adolescents. Adults can usually fend for themselves; children cannot. Any situation that repeatedly stimulates a child is very wrong and can have long lasting and harmful consequences.
Ed, no apology offered.

Angus said...

OK. I believe I understand your view of fetishes and their development.

But what do you think of my suggestion?

Joel Sherman MD said...

Angus, your suggestions are fine. You know better than I do what makes you comfortable. And what doesn't. I don't know how old you are now, but it's much less of an issue for adults.
The situation is best treated by avoiding it. Don't know the details of your initial injuries, but most nurses are reluctant to wash a man's genitals, letting them do it themselves and keeping their genitals covered at all other times. If it needed to be done, they almost surely could have gotten a male nurse or assistant to do it once they saw how you reacted. They should not have come back again and again.
Most asymptomatic adult males over 30-35 don't need regular genital exams. If they self examine reliably, they don't need them under 35 either. Over 50-55 a prostate exam is indicated, but it can be done without any genital exposure, covered lying on your side. As I say, it's best to avoid the problem.

Anonymous said...

Mr. Petersson is right. Why on earth must genital/testicular exams in demonstration videos (and in reality) be done by women? There is not one valid reason for this! It only triggers the fantasies of male and female fetishists instead of encouraging mentally sane men to seek medical help when needed.
And the problem of minors' genital exams would hardly exist if they were performed by a male doctor without the presence of a superfluous female "assistent". It is the plague of "political correctness" and misunderstood "equal access" that makes this obvious solution impossible and even hard to talk about.

Tom Wallace Lyons said...

Nobody in this discussion has touched upon the nature of the fetish that could result from an intimate exam on a young boy. My worry is that a boy might develop an erotic attachment to humiliation if the exam causes him to have an erection. Given the brevity and infrequency of these exams, the erotically charged humiliation may have no long term effect. But can we be sure? A vulnerable adolescent boy is likely to be sexually inexperienced and therefore sexually impressionable. Is it possible that eroticized humiliation can imprint on a small minority of these boys? Do some of these boys develop medical/humiliation fetishes? I can only raise the question. I cannot answer it.

Joel Sherman MD said...

Tom, if you look up a few comments to that of Angus and the responses you'll see that I have indeed discussed this (though not in the original article).
I have not researched the subject of fetishes but I am quite convinced by what I have read that these kind of exams can implant the seed of a fetish. I suspect it is common. It doesn't have to be a medical exam either, it can be any kind of exposure at a young age. Embarrassment seems to be a stimulus to the development of the fetish. I have no idea why they seem to go together.
The subject is worth further exploration here.

Anonymous said...

There is simply no need for this form of intimate examination unless there are prior indicators of some likely problem. Significant pre-existing issues like deformities or abnormalities will have been discovered when the male was examined as a very young child.

Those nations that insist on intimate handling of the genitals of all young men and women (women before they are sexually active, obviously) are not doing so for any medical reason. Instead, like circumcision in the USA, we have something akin to the humiliating 'initiation rites' found in many tribal societies.

Given that most STDs are best detected by the patient in the first instant, visual and manual inspection of the genitals of a young person who has NOT previously suggested a problem is profoundly suspect. Young people, instead, should be given clear simple information in pamphlet or online form, and free access to a humane clinic if they suspect they may have a problem.

A mass of sexual abuse is enabled by the pretence of necessary intimate medical examinations for named groups of non-ill people. Some of the most senior doctors on the planet have been caught mass abusing patients through such programs. The worst abuse tends to occur during medicals forced on people through insurance or workplace schemes, where the doctor involved is likely to see the patient only once.

When the 'pill' was introduced, it was common for women whose only 'crime' was wishing to use this form of contraceptive, to have to strip naked before a doctor every few months and suffer a prolonged 'groping'. What male doctor was going to turn down the opportunity to 'legally' enjoy a healthy young women at the beginning of her sexual life? Back then, doctors didn't even bother with a female chaperone.

Doctors are very smart people, and this is never more clearly shown than at the trial of a doctor caught after years of abuse. The excuses they use to try to avoid conviction prove the vulnerability of patients. Worse, the medical establishment bends over backwards to protect abusers, finding excuses for any behaviour, no matter how horrific, and always promoting the line that patients are unreliable witnesses, no matter how many of them come forward to give evidence against a given doctor.

To conclude, NO intimate examination of any person beyond early childhood unless at the specific request of the patient and/or as a consequence of symptoms that indicate a need for such an exam.

Anonymous said...

"The conclusion from the AAP appears to be that girls should be given a gender preference and boys should not."

Another victory for feminism...

Regarding the video mentioned above...

"I must admit that I have little problem with the video you mention. It's intent is clearly educational and the patient is presumably a volunteer who is not embarrassed."

But that rather misses the point. If an immodest, let-it-all-hang-out type patient is happy for a female doctor to feel his genitals on video, then this still has consequences --- regardless of his consent to this, or any educational merit of the video itself. Male viewers who have more concerns about modesty are that much likelier on seeing the video to avoid such an examination at all costs.

...And they wonder why so many men avoid the doctor like the plague...

Anonymous said...

Recommend you reference this physician blog about hernia exams during sports physicals:

http://more-distractible.org/2009/08/08/turn-your-head-and-cough/

While he doesn't address the provider gender issue at all, he acknowledges the double standard boys are subject to regarding genital exams. Comments, some quite negative as I recall, are now closed.

Ed

Anonymous said...

I have annual complete exams by a nurse practisioner ,have gone to her for 3 yrs. She had a trainee with her on my last visit and asked if she could attend as well,i agreed. I have never been erect on previous exams but on this one ,with both women examining my testicles became fully erect.The young trainee was visibly shaken but my regular nurse was very composed and said men will occassionally become erect during this part so be prepared! I continue to go to her because of her professionalism and thoroughness.I have no concern with her examining my genitals.

Anonymous said...

This is pure fetish. Those here who are serious sbout these issues would prefer that you stay on the porn sites and leave your disgusting accounts there.

Joel Sherman MD said...

I do not know whether the post of 1/19 represents a fetish. But I do know that it is not a rare belief or behavior. We are committed to allowing all civil opinions to be expressed.

Scott George said...

I appreciate this rare discussion of an issue confronting most young men anticipating their genital exams. It is a subject that needs to be openly addressed in medical and nursing schools. I am Executive Director of an organization that does that. We teach the male urogenital exams to medical, nursing, and physician assistant students. I have personally instructed thousands of students over ten years, and have a staff of ten other men who instruct the same. While teaching exam technique, we also emphasize the unique perspective, apprehension, and uneasiness of men as patients. This includes both modesty issues and a false expectation that the male urogenital exams are painful. We address proper advance communication with the male patient that will help them to relax. That would NOT include warning them of a possible erection during the exam, or the suggestion that "you may feel some discomfort". If performed properly the exam should not be physically uncomfortable. As far as patient erections, we recommend that the best prevention is to use firm reasonable pressure when palpating the penis and groin, and to keep the patient engaged in conversation during the exam. DO NOT perform the exam in silence. Also, if the exam is thoroughly performed, in approximately five minutes, there is little time for an erection to occur. If a patient does experience an erection, the student is taught to minimize the patient's embarrassment by casually explaining that it is a normal physical reaction, and to ask the patient if they would like to take a brief break. We actually assist the healthcare student in developing a script that they can use to reduce patient embarrassment on those rare occasions a patient erection might occur. Female healthcare providers are a sizable reality, and should be properly trained to treat male patients, just as with their male counterparts. Unlike the discussion of the unique aspects of treating male patients, the subject of gender suitability and matching has been over emphasized and overly discussed.

Doug Capra said...

Scott:
Thank you for your thoughtful post. I have aquestion about one of your statements: " Unlike the discussion of the unique aspects of treating male patients, the subject of gender suitability and matching has been over emphasized and overly discussed."
I would like to hear more from you as why you think that statement is true, i.e., why gender choice of provider for intimate exams and procedures, is not a basic patient right. I do agree with you that with proper communication, many of these problems can be mitigated. But I also believe there is often an abyss between what medical students are taught in academic contexts and what the learn on the job in the hidden curriculum.I'd also like to year your thoughts on the common practice of chaperones for these kinds of exams and how often, most often, those chaperones are female. I've also heard from several female providers that teenage boys do get erections in these exams more frequently than adults, and that when it happens it happens very quickly. It doesn't take five minutes.
Would you be willing to write an article for your blog. Yours is a valuable perspective.
Doug Capra

Doug Capra said...

Scott:
On my last post I meant to say, would be willing to write an article for our blog about this subject.
Doug

Anonymous said...

In his post, Scott George states that it quite acceptable for females to perform male genital exams and that his health care students are assisted in "developing a script that they can use to reduce patient embarrassment" The self-serving implication here, shared by many in the medical profession, is that if an intimate exam is performed professionally and properly, then gender should not be an issue. In fact, Mr. George writes that, "The subject of gender suitability and matching has been over emphasized and overly discussed." His arguments provide a convenient justification for the medical profession to deny men the right to same gender intimate care.
In reply, I would argue that for me and may other modest men; a genital exam by a female, no matter how professionally done, is unacceptable. An exam of this nature would violate my sense of dignity, my senses of modesty, the exclusivity of my relationship with my wife, my moral values and the values and mores of society in general. An incorrect assumption of Mr. George's post is that men basically have no strongly held value systems and can easily be manipulated if only the proper "script" is used to gain compliance.
No, I do not believe that the subject of gender suitability and matching has been over emphasized and overly discussed but in fact that the opposite is true. It's time for the medical profession to finally acknowledge the "elephant in the exam room" and begin serious efforts to provide more options for male modesty in medical settings.

Joel Sherman MD said...

Scott, I too would like to know why you think that gender is over emphasized in this discussion. As a teacher of nurses and assistants you must instruct a large majority of women so you do have a unique background in this.

In my experience gender is under emphasized in all of medicine in our gender neutral culture. But that doesn't make it valid by itself. Of course as my article makes clear, in our society expressing a gender preference is only likely to work for girls and women. Men and boys are frequently denigrated for expressing similar preferences.

Anonymous said...

Excellent response to Mr. George. I could not agree more. I am quite weary of the condescending lectures from the "experts" as to how our genital exams will be done on their terms. What would be nice would be an explanation as to why a routine genital exam is even necessary? Most men are pretty aware of the condition of their own genitals and probably don't need any female practitioner checking just to be sure. I would consider that quite an intrusion for such little benefit. So for now I think I will follow my own "script".

Anonymous said...

"Unlike the discussion of the unique aspects of treating male patients, the subject of gender suitability and matching has been over emphasized and overly discussed."

A typical patronizing and paternalistic comment by a medical "professional".

Mr. George, while you state, "I appreciate this rare discussion of an issue confronting most young men anticipating their genital exams", at what point do you address patient autonomy, privacy, and dignity and how does that differ from what you teach with respect to young women and pelvic exams and provider gender? While I agree "Female healthcare, providers are a sizable reality, and should be properly trained to treat male patients, just as with their male counterparts", both genders are entitled to the same standard of care and that includes gender preferences!

Ed

Anonymous said...

Erections with boys start the day of the exam. The fear builds all the way to the exam along with the rising and falling of multiple erections.

Then the patient is lead to the room and told to undress.

I think that intervention, the doctor meeting the adolescent patient, fully dressed, with respect, treating them as an adult, taking the history, explaining what will happen, and asking them what they are comfortable with, will go a long way.

The true test will be when the patient refuses to undress or to a part of the exam, how will the provider react? Will they force the issue, or give them a pass to show respect, so next time they will feel empowered and more comfortable and participate.

Anonymous said...

There is no evidence-based reason that these genital exams are done. It is absolutely unbelievable what is done to young people in the name of "medical care". To put an asymptomatic boy through this kind of distress is abuse. Nobody, and I mean nobody should be handling a kid's genitals unless there is symptom that requires it. Which means about 99 percent of kids would never have one. Much psychological damage has been done by these checks, damage indistinguishable from that perpetrated by sex offenders. Parents must stand up for their kids and say No.

Doug Capra said...

Unfortunately, although Scott has some good recommendations and important comments -- he seems to represent the institutional attitude that says:
"Look -- we know what we're doing, so we're just going to go about doing it. There's nothing to discuss when it comes to gender choice. It's overly discussed."
This is the institution focusing on itself, not on the patient. "We're the professionals," they say. "We know what to do. Leave us alone on this."
I firmly disagree with this attitude. Although I laud Scott for the good things he is doing, I do critique what I read as his position that gender doesn't really matter. I agree that good communication can certainly mitigate embarrassing situations for both male and female patients. But I also contend that good communication is too often lacking within American healthcare systems. The result is too many unnecessarily embarrassed and occasionally humiliated, sometimes traumatized patients. And these patients learn to distrust the system.
The system often talks about "patient-centered" care. True patient-centered care will focus more on what works for the patient (within reason), and not what is either convenient or in interest of the system.
I'm sure Scott is a very busy man and doesn't have time to spend much time on this or other blogs. But I interpret his post as taking a shot and then running -- because his worldview is the standard "gender neutral" belief so prevalent within the system. This seems to be Scott's "Truth" with a capital "T" -- for for him, there's no need to discuss it.
This is a good example for people to read who are concerned and willing to discuss this issue openly. It's an attitude you will run into quite frequently. You need to know how to challenge it.

Anonymous said...

A recent study of young Latino males (average age 24) by Oregon State University found:

"In addition, the men expressed a preference for male providers and a need for bilingual providers. Language can be a barrier. At many community clinics, the study participants said the providers did not speak Spanish and translators were sometimes offered."

"Having a third party in the room can be a barrier to trust and honesty," Harvey said. "In addition, the translators were often women, making it even more difficult to discuss sexual topics. And because these are smaller communities, the translators could even be someone they knew."

Follow the link for the complete article.

http://www.news-medical.net/news/20130308/Rural-Latino-men-need-better-sexual-health-services-Study.aspx

Ed

Anonymous said...

I would like to follow up on a post made last December by Tom Wallace Lyons and followed up by Dr Sherman regarding the lasting psychological damage that unnecessary, routine genital exams by opposite sex health care providers can have upon a teenage boy. They both described how such humiliation if combined with stimulation could lead to the development of a fetish.

Well I believe that I am living proof of this. Dr Sherman pointed out in his December post that it doesn't have to be strictly a medical exam either. I have struggled with a strong medical fetish since my early teens and have traced it back to a 'health check' administered by my mother at around that time. Without going in to too much detail, there had been a number of cases of pinworm at my school and my mother thought it sensible to visually inspect my anis for signs of worms by having me bend over and grab my ankles in front of her. Feeling humiliated but powerless to say no, I did as she said. An erection quickly developed.

This memory has played on my mind ever since and has had a huge effect on my life. From that point on, any medical attention whatsoever, no matter how seemingly innocuous such as school eye or hearing screenings would bring on multiple erections both during and prior to the event.

I believe this fetish had prevented me from having normal, healthy sexual relationships and has been a barrier to success in other areas of my life.

I can only guess at how many other people there must be with issues like mine, but to be routinely giving teenage boys their first 'sexual' or 'quasi-sexual' experiences at the hands of female Doctors or female Nurse Practioners in a clinical medical setting must be having adverse effects upon a sizeable number.

I think one thing is clear; the potential for causing lasting psychological damage

Medical Patient Modesty said...

Medical Patient Modesty recently had a video created about unnecessary breast / genital exams at http://www.youtube.com/watch?v=J5glh0ulBjo. Also, check out our sports physical article at http://www.patientmodesty.org/sportsphysicals.aspx. We referred to Dr. Joel Sherman's article about sports physicals a lot.

What happened to the guy in the last posting is very sad. I know of a deaf grown man who was forced to have his mother as an interpreter for a doctor's appointment for an intimate male health issue. It embarrassed him so badly. He wanted his mom to leave, but the doctor said she could not leave.

Medical Patient Modesty said...

It was so sad to read the story of the guy who posted on March 19th. Mothers should not do anal exams on their teenage sons.

This reminds me of an incident involving an adult deaf man who had his mother as an interpreter at an urologist appointment. He asked his mom to leave while the doctor examined his male organs, but the doctor insisted that he stay. This guy was capable of communicating with the doctor via writing.

Many teenage boys have been traumatized by embarrassing medical exams they have. This is exactly why we need to educate parents about the potential psychological damage.

Medical Patient Modesty recently put up a video about unnecessary breast / genital exams for sports physicals. I encourage everyone to watch this video and share it with other people especially parents.

Misty

Joel Sherman MD said...

Thanks for the article Ed. I'll try to get it.
I think there is little doubt that genital exams can be traumatic for some boys, just as they are for girls.
Unlike girls though, boys who get embarrassed and/or stimulated by these exams can later develop fetishes.

Glenn said...

I am really glad that this is being discussed these days. I grew up in the 1960s with leg length discrepancy and mild scoliosis. I had frequent surgeries and exams, and because I was male, nobody cared about my privacy at all. It felt like everybody in the hospital wanted to take a look at me. I remember walking down a hospital corridor in my underwear so doctors could watch my gait.

Even during puberty, privacy was ignored. Doctors didn't ask permission, they just pulled your underwear down if they wanted to look. And I don't ever remember being offered a gown.

This experience did not make me stronger or more resilient. It left me embarrassed about my body and feeling like I was a freak.

Anonymous said...

Since taking training as a medical assistant, I've come away with a more understanding attitude on this. I've only had one experience that was bad. I was recently in the hospital for an epigastric herniorraphy but I was left exposed during recovery for no good reason. The nurse was an absolute witch, and was eventually written-up. I came away from that hospital with more of a sense of being degraded than anything else, merely because there was no medical reason for the exposure.

Anonymous said...

I want to "second" what Glenn said. In my younger years, the family doctor would just pull down a kid's pants and underwear, check whatever they needed to check, and nobody had time to be embarrassed, although I/we was/were.

Another peeve of mine, is siblings getting their exams together, especially during adolescence. I think everyone deserves their privacy and dignity, especially during physical exams. The genital exam is there to check for any problems, or developmental issues, and on that basis, I take no issue with it. But to use such an exam to humiliate a patient, is intolerable. Here's why:

One of the kids in my extended family told me of his age-14 physical and how the doc pulled his underwear all the way down in front of his younger sister and mother, both of whom were snickering about it and making fun of him. However, which it came time for the younger sister's turn to get her genital exam, he was rushed out of the room. Talk about double standards. What's up with that ???

Anonymous said...

I certainly appreciate the need for increased awareness and privacy for our male patients.
That being said, shame on each of you who have suggested nurses take pleasure in provoking an erection in a young male patient! These comments are classic examples of physicians who lack respect for nursing professionals. While there are certainly some nurses out there who are unprofessional or even criminal, I challenge you to open your mind to the reality there exists the same criminality within the medical field. It is, however, not the norm within either profession as your comments suggest is true within nursing.

Anonymous said...

As a patient who has been on the receiving end of healthcare administered by female nurses, who apparently feel our healthcare is a spectator sport, I would argue that it's female nurses who lack respect for the dignity and privacy rights of their male patients.

Ed

Anonymous said...

"Likely this difference is a reflection of the varying importance Western society has put on modesty for women vs. men."

Maybe part of the problem, at least, lies in the use of the word "modesty" in regard to both sexes. Does not the very word have a feminine ring to it? One of the definitions of "modesty" is "The quality or state of being unassuming or moderate in the estimation of ones abilities." Some of the synonyms given are "self-effacement; humility." Are these qualities widely seen as desirable male traits in our society? Does a man who embodies these qualities get to be a general, CEO, or star athlete? As a man, I personally find these qualities to be admirable, but only when balanced with a whole lot of self-confidence and pride. What is truly admirable is to be whatever a given situation calls for. To describe a man merely as "modest" is to rob him of at least half of his manhood. Yes, I know medical modesty is not quite the same thing, but even here, the definition fails many men: "behavior, manner, or appearance intended to avoid impropriety or indecency." This makes us sound like shrinking violets and prudes. Personally, I LOVE "indecency." I positively revel in it, AS LONG AS I CONSENT. When a female nurse or doctor, who is fully clothed, thinks I should allow her to see, touch, and do all sorts of extremely intimate things to my naked male body, I feel that my male pride and dignity are violated. I will not allow a woman such power over me, unless I damn well want to. Just because she has a degree that says she gets to see me naked, that doesn't mean I have to let her. I feel anger, not modesty. What I feel is best defined as "behavior, manner, or appearance designed to avoid loss of dignity, pride, and power." As someone who, through the negligence and incompetence of doctors, has fallen into a never-ending nightmare of hospitals and nursing homes, I have had ENOUGH. I have become a really angry, in-your-face, tough S.O.B. on this issue. I've gotten all sorts of grief about it, from men and women, but I'm fighting back on that, too. Lately, I've been throwing the phrase "gender discrimination" right in their faces. The more they insist I must submit to this routine humiliation, the more recalcitrant I become. My hospital and the various nursing homes I've been in all hate me. I could say much, much more about my experiences, but I'm getting too bogged down in specifics, when I meant to make a general statement. Suffice to say that I don't see myself as "modest" at all. I believe this issue is so deeply seen as pertaining to only women, that the very language used to describe it is feminine. That, in turn, is a big reason for the ridicule that men endure, as well as the reluctance of many men to speak up. Call it "male patient pride," "male patient ego," or "male patient arrogance," even. Any of those is preferable to "male patient modesty." Whatever you call it, the current situation must change.