Letters From Maine: The nether regions

I recently received an e-mail from a pediatrician who described the awkward situation in her community in which many of the other pediatricians don’t include a genital exam as part of their complete physicals.

While patients who have grown up in her practice expect a complete exam, new patients or the patients of other physicians for whom she is covering are surprised. And, it is usually not a pleasant surprise. I assume she doesn’t force the issue, but I am sure that the differing expectations cast an uncomfortable cloud over the clinical encounter.

This is an unpleasant experience that I have shared with her on more than several occasions. Again, the usual scenario is a new patient who has come from "away"(as we say here in Maine). They may already be skeptical about whether any of us here in the North Country ever finished high school and harbor the unspoken concern that "Vacation Land" is a place that attracts sexual deviants.

As much as we would like to present ourselves as scientists, physicians are no less immune to ambivalence and discomfort with issues of a sexual nature. None of us likes to have our genitals examined regardless of the sex of the examiner, and, most of us have a lingering discomfort being the examiner. I suspect that in large part this discomfort is the result of our concerns about what the examinee and his or her parents are thinking.

This doctor’s e-mail raises at least two issues. First, it is another example of the value of continuity. The young patient who has had his or her genitals examined by the same physician at multiple visits over the course of years is less likely to feel uncomfortable about the process, and this comfort level may delay the inevitable onset of the modesty years.

The bigger issue is really a collection of questions. Should pediatricians include a genital exam when they do complete physicals? The obvious and politically correct answer is "yes." But, my correspondent’s experience and my own say that it isn’t happening. As an example, I have often seen 9-month-old girls with nearly complete labial fusion who have been examined multiple times by other physicians. We can argue about whether there is anything we should do about labial fusion, but the bottom line is that no one was looking for it. Do you share our observations about this inconsistency?

What does constitute a genital exam in a 7-year-old? And, what is its value? I don’t have the answers, but I will share my thoughts. I suspect that a hands-off visual inspection is enough most of the time. Is there pubic hair? Do you see two testicles? Does the penis appear normal in size? This kind of an examination takes seconds and doesn’t require a total strip down. But, it would appear that even this briefest of looks isn’t getting done as often as it should.

So, the biggest question is what should be done about this kind of doctor-to-doctor inconsistency? Is it worth doing anything about? It is certainly creating some discomfort for physicians who have to explain and defend their practices to patients they have never met before. Is it an issue for the American Academy of Pediatrics to tackle? Should it be a topic for state chapters or local pediatric societies to address? Or, should it just be kept as a topic for physician-to-physician discussions in group practices?

I will be interested to hear what you all think about venturing into the nether regions.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com.

I recently received an e-mail from a pediatrician who described the awkward situation in her community in which many of the other pediatricians don’t include a genital exam as part of their complete physicals.

While patients who have grown up in her practice expect a complete exam, new patients or the patients of other physicians for whom she is covering are surprised. And, it is usually not a pleasant surprise. I assume she doesn’t force the issue, but I am sure that the differing expectations cast an uncomfortable cloud over the clinical encounter.

This is an unpleasant experience that I have shared with her on more than several occasions. Again, the usual scenario is a new patient who has come from "away"(as we say here in Maine). They may already be skeptical about whether any of us here in the North Country ever finished high school and harbor the unspoken concern that "Vacation Land" is a place that attracts sexual deviants.

As much as we would like to present ourselves as scientists, physicians are no less immune to ambivalence and discomfort with issues of a sexual nature. None of us likes to have our genitals examined regardless of the sex of the examiner, and, most of us have a lingering discomfort being the examiner. I suspect that in large part this discomfort is the result of our concerns about what the examinee and his or her parents are thinking.

This doctor’s e-mail raises at least two issues. First, it is another example of the value of continuity. The young patient who has had his or her genitals examined by the same physician at multiple visits over the course of years is less likely to feel uncomfortable about the process, and this comfort level may delay the inevitable onset of the modesty years.

The bigger issue is really a collection of questions. Should pediatricians include a genital exam when they do complete physicals? The obvious and politically correct answer is "yes." But, my correspondent’s experience and my own say that it isn’t happening. As an example, I have often seen 9-month-old girls with nearly complete labial fusion who have been examined multiple times by other physicians. We can argue about whether there is anything we should do about labial fusion, but the bottom line is that no one was looking for it. Do you share our observations about this inconsistency?

What does constitute a genital exam in a 7-year-old? And, what is its value? I don’t have the answers, but I will share my thoughts. I suspect that a hands-off visual inspection is enough most of the time. Is there pubic hair? Do you see two testicles? Does the penis appear normal in size? This kind of an examination takes seconds and doesn’t require a total strip down. But, it would appear that even this briefest of looks isn’t getting done as often as it should.

So, the biggest question is what should be done about this kind of doctor-to-doctor inconsistency? Is it worth doing anything about? It is certainly creating some discomfort for physicians who have to explain and defend their practices to patients they have never met before. Is it an issue for the American Academy of Pediatrics to tackle? Should it be a topic for state chapters or local pediatric societies to address? Or, should it just be kept as a topic for physician-to-physician discussions in group practices?

I will be interested to hear what you all think about venturing into the nether regions.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com.

I recently received an e-mail from a pediatrician who described the awkward situation in her community in which many of the other pediatricians don’t include a genital exam as part of their complete physicals.

While patients who have grown up in her practice expect a complete exam, new patients or the patients of other physicians for whom she is covering are surprised. And, it is usually not a pleasant surprise. I assume she doesn’t force the issue, but I am sure that the differing expectations cast an uncomfortable cloud over the clinical encounter.

This is an unpleasant experience that I have shared with her on more than several occasions. Again, the usual scenario is a new patient who has come from "away"(as we say here in Maine). They may already be skeptical about whether any of us here in the North Country ever finished high school and harbor the unspoken concern that "Vacation Land" is a place that attracts sexual deviants.

As much as we would like to present ourselves as scientists, physicians are no less immune to ambivalence and discomfort with issues of a sexual nature. None of us likes to have our genitals examined regardless of the sex of the examiner, and, most of us have a lingering discomfort being the examiner. I suspect that in large part this discomfort is the result of our concerns about what the examinee and his or her parents are thinking.

This doctor’s e-mail raises at least two issues. First, it is another example of the value of continuity. The young patient who has had his or her genitals examined by the same physician at multiple visits over the course of years is less likely to feel uncomfortable about the process, and this comfort level may delay the inevitable onset of the modesty years.

The bigger issue is really a collection of questions. Should pediatricians include a genital exam when they do complete physicals? The obvious and politically correct answer is "yes." But, my correspondent’s experience and my own say that it isn’t happening. As an example, I have often seen 9-month-old girls with nearly complete labial fusion who have been examined multiple times by other physicians. We can argue about whether there is anything we should do about labial fusion, but the bottom line is that no one was looking for it. Do you share our observations about this inconsistency?

What does constitute a genital exam in a 7-year-old? And, what is its value? I don’t have the answers, but I will share my thoughts. I suspect that a hands-off visual inspection is enough most of the time. Is there pubic hair? Do you see two testicles? Does the penis appear normal in size? This kind of an examination takes seconds and doesn’t require a total strip down. But, it would appear that even this briefest of looks isn’t getting done as often as it should.

So, the biggest question is what should be done about this kind of doctor-to-doctor inconsistency? Is it worth doing anything about? It is certainly creating some discomfort for physicians who have to explain and defend their practices to patients they have never met before. Is it an issue for the American Academy of Pediatrics to tackle? Should it be a topic for state chapters or local pediatric societies to address? Or, should it just be kept as a topic for physician-to-physician discussions in group practices?

I will be interested to hear what you all think about venturing into the nether regions.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at pdnews@ frontlinemedcom.com.