When Trust Is Broken

abuse
noun
\ə-ˈbyüs\: physical maltreatment

How many of us have children on various sports teams, interacting with doctors and athletic trainers? As pediatricians, how many children do we examine on a daily basis for school physicals and sports physicals?
The abuse case of Larry Nassar (I refuse to call him ‘doctor’), was appalling and disgusting on so many levels. As a parent and pediatrician, I had a visceral reaction. Unfortunately, this was not an isolated case. Although he abused athletes at Michigan State University, the abuse not only continued, but was covered up. This unfortunately allowed this man to continue abusing female athletes on the USA Gymnastics Team.

As a pediatrician, when I examine a patient in my office, I talk to them about the safety of their body and address the topic of who ‘can look at their private parts.’ I always tell my patients that a doctor can examine them WITH their parents’ permission. Before the exam, the patient should change into a gown with privacy and be appropriately draped during the exam. Your child’s pediatrician should be clear with both the patient and the parent/guardian by telling them what and why we are checking during the physical exam. Always ask permission and explain to the parent and child the reason for the exam. For younger children, having a parent in the room during the genital exam is the norm. However, as the patient gets older and depending on the person who has brought them to the visit, having that parent/caregiver in the room may not be comfortable to the patient nor appropriate. In any case, before any sensitive part of the exam is done, the doctor should have a chaperone in the room. Most of the time, this will be a nurse or medical assistant.

What should you expect during your child’s exam?

  • First, the physician will do a complete history. I, personally, then do the entire physical exam with the parent and/or chaperone present.
  • What can you tell your child to expect from this exam? For boys, there is an annual testicular exam. For girls, there will be a breast exam and an external genital exam.
  • There should be no internal/pelvic exam during a routine visit. A pelvic exam is usually done by a gynecologist, with their first pap smear at the age of 21 or 3 years after beginning vaginal intercourse. During the exam, the physician should always wear gloves.
  • The pediatrician will then step out of the room, with the parent, so the patient can get dressed. The pediatrician will then go back into the room to have a one-on-one conversation, often called the HEEADSSS Assessment (Home, Education/Employment, Eating, Activities, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety) with your teen, usually starting at the age of 11. We also start screening for depression (PHQ-9) at this visit. This allows the teenager to speak confidentially with their doctor regarding topics they may not feel comfortable talking about in front of their parent.

As a parent, it is important to start these talks early with your children about what constitutes inappropriate touching. With all the news regarding adults abusing their standing in the community (priests, doctors, teachers, coaches), we need to empower our children to know what is appropriate and what is not. It is never too early to talk to children about healthy sexual development, how their bodies work and what is private. While it may be uncomfortable to broach these topics at a young age, it is vital so your child(ren) knows that they can talk to you when they have questions or concerns. It is important for children to feel comfortable and be heard when they want and/or need to come talk to you.

While this is important for young children as they approach puberty, as in the case with Nassar, the atrocities he committed were with college-level athletes, young women in their late teens/early 20’s. As increasingly more children play high-level, organized sports, they will inevitably spend more time with their coaches and trainers. No athlete should be examined by a physician/trainer alone in an examination room. Period. Feeling safe and comfortable during an examination does not end when the child ages out of pediatrics. Please talk to your children about what constitutes an appropriate sports/athletic focused exam. There will rarely be a reason for the genital area to be examined; and if there is, the athlete should be comfortable, ask questions, and have a chaperone (or parent) during the exam.

Even though we are taught to respect those in powers of position, many in these positions have done horrible things to children, which these victims, now adults, will have to deal with for the rest of their lives. As parents, we must continue to have these open and honest discussions with our children. And as pediatricians, we will continue to do our due diligence to help parents empower their children so they can protect themselves even if they are not there.

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