Genital exams at school physicals and well-child check-ups?

djmatte, ADN, MSN, RN, NP · Mar 11, 2020

1 hour ago, RNMikeMiller said:
I bet the Medical assistant was a female. My friend who is a male had to have a physical for is job. He did not have an option of which provider. Of course the provider was a female NP and the medical assistant was another female. Don't you think that is a double standard that a male patient has 2 females NP & MA in the room, but a female patient will never have 2 males (MD/NP & MA/Nurse)?

It’s a female MA (actually all of our MAs are female At the moment). I’m less concerned about double standards. I do this to protect myself for sure in an environment of litigation. Albeit there is no requirement the other person is of the opposite sex, by some measure there just needs to be a chaperone.

My doctor at the VA is female and I’ve never had a problem with her doing a range of exams. I’d also be limited on my choice of providers given strained resources of the health system. If she turned around tomorrow and said she’d rather have a male do my exam or pulled in a male to observe, I’d be understanding.

People have a range of boundaries and comfort levels. It’s often a fine line, but one that requires honest communication by everyone involved. If I have a clinical reason to do an exam, I articulate it the best I can and if the patient isn’t comfortable with that, they are welcome to see another provider.

RNMikeMiller · Mar 12, 2020

@djmatte I like the fact that your a male NP. The key statement is "It’s a female MA (actually all of our MAs are female At the moment)." That is the problem at most places is that they hire all females and not male MA, RN, PA, etc. to cover the basics.

RNMikeMiller · Mar 12, 2020

On 12/9/2019 at 8:46 PM, AmyB_NP said:
Do you perform any kind of genital exam at yearly school physicals and well-child check-ups? If so, what does the exam consist of?
For boys, I always check their testicles, and once they get to be around 10 or so, I also start checking for hernias and for a tight foreskin (if they haven't been circumcised). For girls, unless they have an issue, I'll usually just take a quick look down their waistband to check tanner stage until they start their period.
However, I was talking to a colleague, and she said I'm being too thorough, and that the only kind of genital exam she regularly performs is a hernia check when a boy is getting a sports physical.

@AmyB_NP

I think it is best to opt out and NEVER have a female doctor or NP give a teen boy a sport physical again. This is what happen at my son's middle school last year. That is why he does not want to play soccer this Spring because he was embarrassed to death. I wanted to file a complaint with the school and NP but I did not want to embarrassed him mentally more than he has been physically.

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. 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."

STOP embarrassing boys with female doctors and NP so they will not play sports!

Found this article that everyone should read
https://www.kevinmd.com/blog/2011/08/sports-physicals-includes-provisions-privacy.html

djmatte, ADN, MSN, RN, NP · Mar 12, 2020

29 minutes ago, RNMikeMiller said:
@djmatte I like the fact that your a male NP. The key statement is "It’s a female MA (actually all of our MAs are female At the moment)." That is the problem at most places is that they hire all females and not male MA, RN, PA, etc. to cover the basics.

Our clinic group has multiple sites. This one specifically has mostly male providers who are here regularly while the females are here less days a week. Other sites have females there everyday and the males are there less frequently. Between multiple sites, there is always room for accommodation.

I'm not sure what's the point of fixating on these ratios or why there's such animosity to these situations. Accommodating a range of genders is good practice for sure. Who we hire has less to do with gender and more to do with the applicant pool. In two years of working here, I have only seen three male MAs brought on board and two of them didn't last wrong in those roles. It isn't an entry level job many men go into. Especially in a region saturated with factories who can pay more for less front-loaded certifications.

At the end of the day though, I'm a military guy. I take the dish I am given and just add some hot sauce if I need it. Outside overt unprofessional behavior, I don't see the point of being embarrassed or uncomfortable with who sees me in the clinic. But mileage may vary. Everyone has their own bag and history, so I try not to be offended or put off if someone doesn't want to see me for whatever reason.

djmatte, ADN, MSN, RN, NP · Mar 12, 2020

1 hour ago, RNMikeMiller said:
@AmyB_NP

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. 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.

There is some clinical rationale for checking for hernias and specifically focused on boys over girls. I don't have online guidelines, but my physical exam texts suggest that inguinal hernia incidence is around 4%. We check boys specifically here because they have a 6 to 1 higher likelihood of having them compared to females. Comfort level with who does these exams should be individualized for sure where possible. But at the end of the day, interactions such as these which are THAT traumatizing would cause me concern as a parent for something more problematic afoot.

discomonkey · Sep 9, 2020

On 12/19/2019 at 10:14 AM, FiremedicMike said:

Brother, I'm want to believe you mean well and are trying to learn, but literally ALL of your posts are regarding juvenile genitals.

It creeps me out.

He's just looking for advice about how to get children to open up about their genitals with him. And to be fair, there was at least one post where he asked about breasts. "Do you actually look at there lady parts...?" Clearly he's been to nursing school.

MarkMyWords · Sep 15, 2020

Are these genital exams really necessary? What is the probability that something is wrong down there? What are the real chances? Is this curiosity? I am not a nurse, but I say skip it as part of routine care. They are being humiliated for no good reason. If this inspection is "important", then why only children and teens? Why not inspect everyone like that in a physical? Because most adults won't do it and you could get into trouble. They would probably complain. It's uncalled for in physicals, but kids won't complain, and call lawyers.

djmatte, ADN, MSN, RN, NP · Sep 16, 2020

On 9/15/2020 at 10:14 AM, Mywords1 said:

Are these genital exams really necessary? What is the probability that something is wrong down there? What are the real chances? Is this curiosity? I am not a nurse, but I say skip it as part of routine care. They are being humiliated for no good reason. If this inspection is "important", then why only children and teens? Why not inspect everyone like that in a physical? Because most adults won't do it and you could get into trouble. They would probably complain. It's uncalled for in physicals, but kids won't complain, and call lawyers.

"Standards of care" vary broadly throughout specialties and is very prominent in primary care. There are a range of guidelines we try to follow while others are often willfully downplayed unless there is a reason to follow them. "Important" comes down the the view of the provider and should be with input from the family and/or patient. Much of it still comes down to circumstances and the specific reasons for the exams. Equally, there are doctors who see adults who want to see that person top to bottom because often it's their eye that could depict a range of conditions a patient may never notice or bring as a concern. Again, it often comes down to how thorough a provider would prefer.

Speaking to situational circumstances, teens specifically are often checked for things like hernias when they play contact sports. Most sports physicals actually have locations on their forms verifying it was done. This is for liability purposes because those sports can exacerbate a hernia and it's geared toward males because males are 4 times more likely to get them. I have no specific interest in doing this exam and I recognize it's embarrassing for the teen. But at the end of the day, if I can't verify there isn't a hernia present, I won't sign off a release so a child can play a sport. I do paps and pelvics in accordance with ACOG recommendations. Not all women prefer a male does them and I gladly refer (or recommend a female colleague). I ensure my documentation is noted because if they fail to get it done and end up with cancer, I am hopefully protected. Again, liability.

Another consideration is it doesn't take much for a lawyer to suggest what should be a "standard of care" through a range of medical literature should the provider choose to skip an examination; even if documenting "deferred" (absent of patient refusal). Should something be missed, there could be an opportunity for a lawsuit. Patient's aren't expected to know what a range of skin cancer looks like (among other conditions) and many expect their doctor to have the wherewithal to perform standard tests and perform actual primary prevention.

At the end of the day, communication of the necessity, the why, and the plan should always be happening interactively with a patient. If they don't agree with any of them, then defer and be clear the patient/family declined the evaluation. But I would be exceptionally clear in all documentation to protect myself in those cases.

Rnis, BSN, DNP, APRN, NP · Sep 17, 2020

On 12/13/2019 at 9:33 AM, Hoosier_RN said:

Same here. During exam with my oldest son, MD thought she found something in testicular exam. Luckily, ended up to be nothing. But, both my sons were taught testicular exams, and to let her know if they noticed anything unusual with any body system or its functioning. Females should be taught BSEs. So many kids don't know how to do this, if they even know about doing this. They may be embarrassed to ask how. Do the exam and explain/teach while doing so. An ounce of prevention...

The USPTF actually recommends against testicular screening in both adolescents and adult males. (grade D) Most cases are found incidentally by a patient or their partner and there isn't evidence to support a benefit of provider screening.

I don't screen, but I do discuss testicular cancer and hernia's with adolescent patient's and the need to seek help if they notice a bulge or mass.

I made this change early in my practice after seeing the anxiety in my patient's and some of their fathers even taunting them about this. I do think it is important to assess for Tanner's stages but some of that can be done by discussion or visuals of other characteristics.

The recommendations aren't there for breast exams either but I have a harder time not doing that one. I do tell patient's recommendations are changing but still recommend a breast exam. Most still elect to have a breast exam. But even if they don't want an exam I still have a discussion with them about changes to their breast that would warrant further evaluation.

djmatte, ADN, MSN, RN, NP · Sep 17, 2020

54 minutes ago, Rnis said:

The USPTF actually recommends against testicular screening in both adolescents and adult males. (grade D) Most cases are found incidentally by a patient or their partner and there isn't evidence to support a benefit of provider screening.

I don't screen, but I do discuss testicular cancer and hernia's with adolescent patient's and the need to seek help if they notice a bulge or mass.

I made this change early in my practice after seeing the anxiety in my patient's and some of their fathers even taunting them about this.     I do think it is important to assess for Tanner's stages but some of that can be done by discussion or visuals of other characteristics.

The recommendations aren't there for breast exams either but I have a harder time not doing that one.   I do tell patient's recommendations are changing but still recommend a breast exam. Most still elect to have a breast exam. But even if they don't want an exam I still have a discussion with them about changes to their breast that would warrant further evaluation.

Are you talking testicular cancer screening or hernia screening (eg sports physicals). To my knowledge the latter USPSTF recommendations don’t exist. Something to consider, I had a double hernia that was only caught on my sports physical before I was about to play football at 12. All of my years of regularly seeing a pediatrician and it was never noticed. This is where my concern comes when people arbitrarily defer but still opt to sign off on sports.

Anon0100 · Apr 19, 2021

“It is very disturbing that some school districts such as this school district in New York require breast exams for girls and genital exams for boys as part of physical exams. This school gave out a handout encouraging parents to prepare their child for breast / genital exams. This is horrible. Children should never be forced to have breast or genital exams for physicals. There is no evidence that these are necessary to ensure safety of playing sports.”

By no evidence it means quite literally none, zero.

Check yourself the day before then refuse when asked and say why. Or just refuse and ask why it's necessary, when they give you the "It's important for your health" bs make sure to make them feel stupid by stating there's no evidence what so ever that says it's necessary to ensure safety, and that there's also none saying a asymptomatic hernia, for instance, will impair your ability to play. (If you didn't/don't have a asymptomatic one, you'd definitely know so checking wouldn't be necessary, only a form of care for it if needed.) If they still insist they're one of 2 things. Stubborn and uneducated, or a pedophile. Simple.

Go to a different doctor.

Doctors on blogs seem to like posting about the events, too. Whether you run into them yourself or read about it on articles. I've seen both, some of them even admit they know there's no point and could skip it but don't. As if they enjoy it. Weird, right? I don't expect patients to trust me with those kinds of things unless needed, and don't want them to. Tbh, I myself have never liked doctors for reasons like this. Ironic, right?

Juliesteph444 · Nov 25, 2021

What do the regulations specify? Do they not indicate how and when any and all physical examinations are to occur? If not, that would be a major red flag; if it's not specified in a reg, yet the expectation is there, the liability falls to the teacher if there are issues (especially in the court of public opinion). In your profession, with the present cultural chaos associated with schools, and rampant litigiousness, I would demand a reg before doing any further exams.