Sports physicals often includes no provisions for privacy

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.

Joel Sherman is a cardiologist who blogs at Medical Privacy, A Patient Oriented Discussion.

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  • http://twitter.com/hisel13 Patrick Hisel

    I used to think hernia checks in males was useless until I found a hernia in a jr high kid trying out for football…quarterback.  Imagine a helmet direct hit to the hernia.  So now I do hernia checks at least once.  For an athlete’s follow up physical I don’t typically do them if the previous one was normal.

  • http://pulse.yahoo.com/_ELW6GYBWHE6VZFXRO7TOCM5T7M muscleman

    For young men, sports physicals and military induction physicals share several similarities. Often there are
    female observers who have no business being there. Think of them as peeping tom perverts. Fortunately the
    military placed guidelines in 2003 and certainly our schools should too.
      This is the hallmark of CFNM(clothed female naked male fetish).

  • Anonymous

    There are some excellent points in this articles, but we need to put in to perspective that somewhere around 15% of adolescent males will have a varicocele.  Most of these are asymptomatic and for many teen males, the sports physical is the most thorough physical they have every year. In 37 years of practice and in performing hundreds of sports exams every year, many teen males tell me they have not had genital exams during their “yearly physical” (if they even have had one) and almost all of the teens with varicoceles are entirely unaware that they have them.  So, while varicoceles do not disqualify males from sports, they certainly need to be addressed and evaluated as infertility is a possibility. Privacy is an important issue… I agree, but not doing a genital exam is not the answer to this issue.

  • http://profiles.google.com/joel.sherman Joel Sherman

    jasdisqus040549′s point is valid, but could be applied to nearly any condition.  Indeed if female genital exams were done a few significant abnormalities unrelated to sports safety would be found as well, but that is not the object of a sports physical.  If the physician can combine a sport’s physical with a complete exam and do it protecting the kid’s privacy, that is fine, but it is not practicable for group sports physicals.  One cannot expect a group physical to replace a comprehensive exam which should be recommended for any child.

    • Anonymous

      Thank you, Joel.  I appreciate your reply. As an adolescent medicine specialist, I strongly agree, too, that privacy is a huge factor/ consideration for all teens.The reality of all this is that where I work (urban, inner city) more than one half of teen males I see do not have a doctor they see regularly and for all practical purposes, the sports physical is the ONLY yearly exam they get. Our project has a mobile unit and the vast majority of our exams are performed in a private office so that privacy is not a factor. However, going back to my previous statement, the sports physical may be the only time for a genital exam to be performed and I feel we should seize the opportunity.  As for privacy in a group setting, there can and should be a station in a separate room where the genital exam can be done in “privacy.” The times that I have participated in group physical, that is how it is/ was always done.
      One added comment, when we look at the SPE goals, there are times (especially in my teen population) we need to look a bit past those immediate goals and, if possible, add in some of the “yearly physical goals” when we can. Such is the case with male genital exams. It is listed as part of the REQUIRED physical… why not do it while we have that opportunity? 

  • Hexanchus t

    I don’t believe that anything that is not relevant to sports participation should be a required element of a sports physical. The athlete should be free to refuse any such element without being penalized.

    The problem I see is lack of informed consent. By including elements not related to participation, the examiner is effectively going on a witch hunt beyond the stated purpose of the exam, potentially invalidating the consent (i.e. obtaining it under false pretenses). If you feel these exam elements are important, then tell the athlete why and give them the option to include it or not.

    I also strongly agree that privacy and modesty of the student athlete must be respected. Any exams involving intimate exposure should be done in a private setting out of both sight and hearing of others. If the athlete has a preference for the gender of the examiner that must be respected, and they have the absolute right not to have a chaperone or other observer present, or at the very least choose the gender of a chaperone they are most comfortable with.

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