Asmall girl is brought to the doctor by her mother because she is complaining of pain in her "private area."
After asking some questions, the doctor, who suspects vaginal lesions, says he'll have to take a closer look, possibly doing a pelvic exam. The mother is gripped with fear. How will this small girl endure such a grown-up exam?
The doctor explains the procedure to the girl, who begins to cry. The doctor now has an uncooperative patient, which will make for a very difficult exam or no exam at all. How can he best handle such a delicate situation?
Family physicians wrestled with hypothetical and real-life situations like this at the American Academy of Family Physicians Scientific Assembly last weekend in New Orleans.
Pediatric gynecology isn't a subject doctors learn much about during their medical training, said Dr. Thomas Irons, a professor of pediatrics at the East Carolina University School of Medicine, who presented a lecture on the subject.
"We brush it aside because nobody wants to deal with it," Irons said. "Culturally we are very sensitive to the idea of examining the private parts of a little girl."
Irons said doctors' fears are also rooted in avoiding the quagmire of being accused of sexual impropriety.
Pediatric and adolescent gynecology are gaining more notice nowadays in light of increased sexual activity and heightened awareness of sexual abuse among the young.
And increasingly, the medical community is realizing that pediatric gynecology and adolescent gynecology aren't oxymorons.
Using color slides, Irons took doctors through a gamut of gynecologic problems they might see in young girls: straddle injuries, foreign bodies lodged in the vagina (toilet paper is the most common item), prepubertal conditions, discharges, bleeding, rashes, genital anomalies, sexually transmitted diseases and sexual abuse.
All warrant a closer look, but getting to that point isn't easy.
"I see mothers bringing in their daughters with symptoms the girl has put up with for two years--problems a grown woman would never put up with for more than two weeks," said Dr. Susan Pokorny, head of obstetrics and gynecology at Kelsey Seybolt Clinic in Houston and past president of the North American Society of Pediatric and Adolescent Gynecology, an organization made up of 482 physicians.
"There is 50% of the childhood population that has never had a very important part of their anatomy examined," Pokorny said. She doesn't advocate pelvic exams for every young girl, but knowing what is normal for that child is essential.
The field of gynecology focusing on young girls has been around since the 1930s and grew from an interest in learning more about genital abnormalities on the pediatric side, and a concern about teen sexual issues on the adolescent side, said Dr. Alvin Goldfarb, a Philadelphia gynecologist and president of NASPAG.
Goldfarb said NASPAG's goal is to lead the health care profession in knowing how to deal with gynecologic issues among youngsters. But he said it will be the next decade before doctors are comfortable with the following:
* Talking about sexual issues to adolescents younger than 14.
* Looking at external genitalia on young girls so that they may determine what's normal and what's not.
* Knowing the appropriate methods for gynecologic examinations on youngsters and demonstrating this to patients.
* Knowing when to refer cases to a specialist.
In August, a Lancaster Community Hospital emergency room physician was accused by sheriff's deputies of mistreating a 4-year-old rape victim who was brought to the hospital. The sole deputy in the examining room said Dr. Christine Daniel made the victim wait, treated her roughly and refused to complete the exam.
But Daniel said she wanted further investigation by a pediatric gynecologist because she found evidence of previous sexual abuse--bruising that looked darker and older than the most recent sexual attack.
In sexual abuse cases, the biggest concern is that the child doesn't see the exam as another episode of abuse, said Dr. Kenneth Schikler, director of adolescent medicine and rheumatology at the University of Louisville School of Medicine in Louisville, Ky.
"[Children] should understand the purpose of the exam and that they should let us know immediately if they are in pain. In a sense, this empowers them to be in control of their own exam. We want them to understand that the exam is for their benefit alone. It is a way to make sure they are as healthy as they should be."
Schikler said the same applies to the sexually active girl who is having her first exam.
"Even a sexually active early adolescent has ambivalent feelings about their sexual behaviors. That carries over to their idea of the exam," Schikler said.
"They see the speculum and don't understand how it will be used. The stirrups look threatening too. They don't understand the whole process. They've heard from peers, siblings and their own mothers about negative experiences."
Said Dr. Janice Neuman, family physician and program director for the Kaiser Permanente Fontana family medicine program: "Doctors really need to talk the girl through the exam."
Girls, she said, are usually sexually active for a year before they seek medical attention. Sexual inquiries are often the hidden agenda of teens coming in with unrelated complaints. For example, they'll say, "I have a cold," and in the same visit they'll ask about contraception. This is one reason Neuman and her colleagues who work with teens advocate routine checkups.
"If they were coming in more regularly they could develop a rapport with their doctor," said Dr. Marvin Belzer, medical director for the Teenage Health Center at Childrens Hospital Los Angeles. "Teenage bodies are changing so rapidly they should be looked at routinely."
Belzer said that while most girls come in at this age with menstrual complaints, he finds it is a perfect opportunity for a physician to talk to her about her sexuality. "If she knows and trusts her doctor she is less likely to be embarrassed by the situation."
Added Pokorny: "By seeing girls before they are sexually active, we can empower them with knowledge about their own bodies. The system now screens out those who aren't sexually active as those who don't need seeing. This puts the cart before the horse."