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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