8
29Jun
2015

Turn Your Head and Cough: A Teenager’s Nightmare

frog on a rock

Dear Adolescent Boys,

Whenever I tell you that a genital exam is part of your annual well child check, your eyeballs fall out of your head in complete horror. The expression on your face makes me feel like my office is a haunted house, and you just saw a goblin for the first time ever. In other words, you act like you had ABSOLUTELY NO IDEA WHAT YOU WERE IN FOR.

I have a hard time deciphering this behavior. I’m not sure if you’re putting on a show to get out of the exam, or if you really are that mentally unprepared and completely clueless as to what would happen at your “well child check”.

First, let’s get the terminology out of the way, because the word “child” is a little off-putting. A well child check is the politically correct terminology for your annual physical exam. It is technically called a “well child exam” until you reach the age of 18. I’m sorry we call you a child. I know, the term makes you hate the pediatrician even more because you already feel too big and too grown up to visit a waiting room full of crying babies and kiddie toys. We should really call your yearly physical exams, “well adolescent checks” or “well adolescent exams”. Unfortunately, whatever term we choose to use, we’ll always be dorky to you because you’re a cool cat now — you have your driver’s license, you have a girlfriend, and you’re the drummer in a band.

I recommend that you get a routine physical exam once a year, for every year of your life! This includes every year up until you turn 18 and then one at age 19, 20, 21, etc.

It is standard for your well adolescent check to include a genital exam. Your doctor should ask for your consent before doing it. Most of the time, you say no anyways. But sometimes you say yes.

You should know why physicians do a male genital exam on adolescents. There are four main reasons:

  1. To make sure you don’t have testicular cancer. Testicular cancer can occur at any age.
  2. To make sure you don’t have an inguinal hernia. This is where your guts come out of your abdomen in all the wrong places.
  3. To do a sexual maturity rating (SMR). This is where we make sure your sexual development is on par with your age.
  4. To make sure everything is normal.

It’s true that routine male genital exams are controversial. In other words, some physicians think that it is unnecessary to do them on a regular basis. The USPSTF (a fancy acronym for an organization that sets the standards for health prevention & screening) actually recommends against testicular exams as a means to screen for testicular cancer in adolescent men. Some argue that routine hernia exams aren’t even necessary. A concerning inguinal hernia will most likely cause symptoms. A hernia found on exam without symptoms is usually a “watch and wait” situation.

If you feel uncomfortable about your genital exam, the best thing you can do is voice that discomfort to your physician. Have a conversation about the exam beforehand. Discuss specifically why you don’t want to get it done. The ability to have these conversations with your doctor helps to develop the skill set you need to comfortably talk about sex and your genitals with your peers. If you can’t talk about your genitals with your physician, how will you be able to discuss them with your future partner?

One last thing all guys everywhere need to know. When a physician checks for hernias, he or she will say the classic phrase associated with the male genital exam. Say it with me now:

“Turn your head and cough.”

This is NOT to distract you from the discomfort of the exam. The cough adds force to any guts that may be protruding in the wrong place, so that your physician can more easily detect them. In other words, the cough increases intra-abdominal pressure to accentuate the hernia to aid in diagnosis. The reason we ask you to turn your head is so that you don’t cough all over us. Brilliant, right?

Some physicians actually require a chaperone to be present during the genital exam. They do this for not only your protection and safety but also for legal purposes. In my practice, I require a parent to be in the room during the male genital exam, but the parent doesn’t have to watch directly.

Lastly, please note that some guys do incidentally get an erection during the male genital exam. It happens and there’s not much you can do about it.

K, so promise me, that the next time it’s your turn for a male genital exam, and you feel awkward and weird, that you’ll talk to your doctor about how you feel about the exam rather than acting like you had ABSOLUTELY NO IDEA WHAT YOU WERE IN FOR. Because now you know.

 

Sincerely,

Dr. Archer

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8 Responses

  1. archie

    This is one of the best explanations on pediatric genital exam. You say, “You [patients] sometimes say yes…” I can see why they would say yes when you have such an attitude that actually cares about your patients’ dignity.

    Kudos for you. I would not allow you to do a genital exam on me during a PE, but I would feel comfortable bringing up a problem with you if I had one down there. Too many physicians say it is part of the exam and you are getting one to the point of coercion (I can provide references to this). They don’t mention informed consent (or any consent); they take silence to equal consent.

    There are a couple of issues that I have with this post; First off you should be meeting with your patients fully dressed before the physical exam to discuss what should happen, take history, gain consent, etc. This is called “trauma informed care.” This is also recommended in AAP, AMA, and the rest of the alphabet soup of organizations’ guidelines.

    Next I want to talk about chaperones. Again AAP, AMA, etc. all say that chaperone use should be a SHARED decision between physician and patient. This applies to parents as chaperones as well.

    The 1981 study, “Teenagers’ preferences regarding the presence of family members, peers, and chaperones during examination of genitalia,” on the NIH/PubMed website (http://www.ncbi.nlm.nih.gov/pubmed/7312468?dopt=Abstract&holding=f1000,f1000m,isrctn) concludes:

    “With increasing age, males preferred to be alone with the physician whereas females preferred to be accompanied. Regardless of sex and age, virtually none chose the company of peers. Despite strong development differences, however, there also were pronounced individual differences among teenagers of the same age. Our results suggest that service delivery be adapted to the particular preference expressed by individual teenagers.”

    Many providers are unaware that genital exams can be perceived as “nosocomial sexual abuse” (Money J., Lamacz M: Genital examination and exposure experienced as nosocomial sexual abuse in childhood. J. Nervous and Mental Diseases, Vol 175, No 12, pp713-720, [1987]) and can cause PTSD (http://www.tandfonline.com/doi/abs/10.1080/02646839308403222?journalCode=cjri20&#.VLGAe3uqEuN).

    Again, kudos to you because you HAVE addressed this in (I assume by the “sometimes yes” statement) that the patients say no, a GE is NOT preformed, and their decision respected.

    You bold face “The ability to have these conversations with your doctor helps to develop the skill set you need to comfortably talk about sex and your genitals with your peers.” Again I give you credit for allowing parents to be chaperones and not having to directly watch. Too many physicians say there HAS to be a chaperone and NOT the parent, justified by the patient getting older (which is forcing a chaperone that is employed by the provider’s practice).

    You say, “They do this for not only your protection and safety but also for legal purposes.” You fail to mention that the chaperone is there for YOUR protection also. (Is that the legal purposes?”) PLEASE BE COMPLETELY HONEST! I would argue that a chaperone is solely for the physician’s protection, and they do NOT always protect the patient. See the NIH/PubMed resource “Chaperones: are we protecting patients?” (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148245/)

    I know this is a UK study, but look at the United States cases of Dr. Twana Sparks, an ENT who [sexually] abused patients in front of other medical personnel and is still practicing (http://www.outpatientsurgery.net/resources/forms/2010/pdf/OutpatientSurgeryMagazine_1001_ent.pdf), or the $500,000 verdict against anesthesiologist Tiffany M. Ingham who verbally abused a patient in front of other medical personnel (http://www.washingtonpost.com/local/anesthesiologist-trashes-sedated-patient-jury-orders-her-to-pay-500000/2015/06/23/cae05c00-18f3-11e5-ab92-c75ae6ab94b5_story.html).

    I also hope that you also take this approach with female patients too. The dirty little secret is that the double standard to discriminate (and abuse) males is taught in the formal medical curriculum:

    “Genitalia: Boys always; girls when indicated (e.g. all sexually active girls and those with any symptomatology) should have an external inspection and an internal pelvic examination. Desirably, all adolescent girls should have pelvic examination at some time as a matter of routine.” Hofmann, A and Greydanus, DE; Adolescent Medicine, 2nd Edition, 1989.

    …and everyone wonders why men avoid healthcare.

    Do you even have a male chaperone to offer? (I actually believe that you do.)

    Looking at your profile picture can you understand why a male adolescent may decline a genital exam (especially) from you (an attractive, younger female)??? Is that not obvious?

    Let me finish this critique on a positive: You are an incredibly compassionate person and I am sure an excellent physician for not only letting your male patients know that they can refuse a genital exam, but for accepting their decision!

    –Archie B

    Reply

    Dr. Archer Atkins

    Hi Archie,

    Thank you so much for your kind and thoughtful reply!

    I do want to correct one thing that you said, “First off you should be meeting with your patients fully dressed before the physical exam to discuss what should happen, take history, gain consent.” I do this — the discussion about the genital exam, taking history, and gaining consent all occur while the patient is fully clothed. Perhaps because I took a creative approach on this topic in the form of a letter to an adolescent, it was less clear. I can try to make that clearer in my letter if I get a chance! I do know that some physicians take history during the physical exam as a means to save time.

    Thank you again for all your thoughts and sharing all the research that you did!

    I, too, have found it very interesting in how boys and girls are treated differently when it comes to routine physical exams.

    Reply

  2. archie

    You are correct in that I did not catch that you discuss with your patients while dressed.

    I think a more important question is why are your so different (in the good way) than most providers?

    I have worked with people who were abused in healthcare settings and see the damage that has been done. One person (a friend of a friend) refused to be treated for prostate cancer and died an agonizing death, refusing to put himself through the mental trauma he had endured previously in healthcare.

    Probably the most disturbing paper that I have ever read about the way providers treat patients (even more disturbing than Dr. Peter Ubel’s 2003 “Don’t ask, don’t tell” http://www.ajog.org/article/S0002-9378(02)71415-4/abstract) is Joan P. Emerson’s “Behaviour in Private Places: Sustaining Definitions of Reality in Gynecological Examinations.” (http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1312385)

    The sad reality is that in 2012 we are still having these conversations. (https://www.psychologytoday.com/blog/critical-decisions/201208/inappropriate-touching-in-the-doctor-s-office)

    Again thank you for a sensitive approach to healthcare that respects patient autonomy and dignity and putting the truth out there on your blog.

    –Archie B

    Reply

  3. Life With Teens & Other Wild Things

    Wow. I haven’t often seen such an articulate explanation for boys from a medical provider. We talk so often about teaching our young children and girls about consent and body safety, but even though I consider myself well informed on those topics, it never occurred to me to discuss with my son the fact that he does have the right to consent (or not) to a genital exam during his normal physicals.

    This is very informative and I’ll be sharing it with my son, as well as with my (admittedly rather small) Facebook community. Thank you so much for a sensitive and well presented piece.

    Reply

  4. Vivian

    Wow, this article reminded me of my oldest son :)
    But I have a couple of questions…

    What age do you start doing the genital exam for males? If a male is uncircumcised do you retract his foreskin? And do you not do a breast/genital exam for female patients?

    Reply

  5. RLU

    It is good that you are trying to educate teenage boys, but most of your patients will not have seen this article and so they will be surprised when they find out you need to do a genital exam. Their having absolutely no idea what they were in for is to be expected.

    When I was a teenager having my mother in the room would have made what is already an embarrassing exam into a humiliating one, whether she was looking or not, because I’d of had no way of knowing if she was looking. Something that you can do to address this situation is to tell the patients at the time the appt. is being made that this will occur so that the boys can have their Dads bring them instead of Mom, or even alternatively to switch to a male pediatrician. Clearly that isn’t good for your business should they switch, but having a humiliated patient isn’t a good thing either. That you are comfortable doing the exams and totally professional and clinical doesn’t make it not be embarrassing for the teenage boy. When my daughter became a teen, my wife found her a female pediatrician when she was no longer comfortable getting examined by the male pediatrician she had seen since she was a toddler. Our son kept going to the male pediatrician until he went off to college.

    Reply

    archie

    RLU,

    No physician ever NEEDS to do a genital exam on a patient unless there is a specific, genital complaint (even then many times the physical exam may be deferred if lab testing used). The only legal requirement is that one (a genital exam) be OFFERED as part of a comprehensive physical exam. The basis of this is the Federal Medicare/Medicaid laws to ensure that patients are at least offered comprehensive care.

    Any documentation that says “NEEDS to be” or “MUST be” is directed at providers by 3rd party payors in that component of a comprehensive physical exam must be OFFERED and ATTEMPTED to get full reimbursement. Note that despite wording saying it must be completed, every billing form will provide FULL reimbursement as long as the provider documents it was offered, attempted, and the reasons it was not completed.

    Saying that it MUST be done would nullify the informed consent/informed refusal process and open providers up to a whole host of other problems. Part of this confusion stems from guidelines saying that this part of the exam must be included, but that is directed at the doctors and NOT at the patients.

    Dr. Archer is a very good physician and takes the issue of informed consent/informed refusal very seriously. Not where she states:

    “Most of the time, you say no anyways. But sometimes you say yes.”

    She obviously explains the importance of this exam and respects patient autonomy. She also (obviously) does it in a thoughtful, sensitive, and respectful way that builds the trust of her patients because some say “yes.”

    Dr. Archer is also aware that this may be an issue for some patients and it appears that she brings the issue up before hand to ensure the patient is prepared. Forcing a patient to go through when they are not mentally prepared or do not want it done can be traumatic for a person.

    She also realizes that adverse experiences with healthcare when one is young will cause one to avoid healthcare when older. Dr. Archer is preparing her patients to take control of their own healthcare. This is evident when she states:

    “The ability to have these conversations with your doctor helps to develop the skill set you need to comfortably talk about sex and your genitals with your peers.”

    Responsibility includes not only knowing when you need something, but also knowing when it is NOT needed. In the same way Dr. Archer mentions the USPSTF (showing that she is up to date on guidelines) which is to help doctors decide when something is unnecessary.

    Reply

    RLU

    archie, I can tell that Dr. Atkins is a good doctor but if the first time the teenage boy hears that the doctor suggests doing a genital exam is when he’s in the room with her and his mother, even though she is doing an excellent job explaining why it should be done he’s only going to be hearing half of what she says. Sending the letter in advance of his visit would allow him to digest the info and to have his dad bring him instead.

    When I was a teenager even if I accepted Dr. Atkins explanation of why I should let her do the examination, I’d of still said no because she was going to let my mother watch. I understand her need to protect herself legally but having a male staff member chaperone would be far more humane. She’d get more yes answers from the boys that way. Saying the boy’s mother doesn’t have to directly watch is of little comfort to the boy.

    Another aspect of this that she is missing is that she is setting up the boy for a potential conflict at home. He says no because he doesn’t want his mother there and then he gets bullied or shamed afterwards with “I changed your diapers, it would have been OK for me to observe the exam”. There is no reasonable way Dr. Atkins could know the dynamics of her teenage patient’s households in this regard. Dr. Atkins wants to help her teenage male patients. That is good and she deserves praise for that, but she’s really not getting it with the mothers in the room part of this.

    Reply

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