Opinion: How a missed period reported by the gym teacher could spell trouble for girls
Editor’s note: Megan Ranney, MD, MPH, is assistant dean of the Brown University School of Public Health and professor of emergency medicine at the University’s Warren Alpert School of Medicine. The opinions expressed in this commentary are his own. Read more reviews on CNN.
As a doctor, public health professional, and parent of a teenage girl, I have followed with interest and concern news of a Florida school district’s decision to digitize children’s athletic records.
What should be a simple decision on best medical practices has been turned into a Gordian knot not just of health, but of politics, politics, technology, and bodily autonomy.
Being active is obviously important for children, in general. We should do all we can to encourage all young people to engage in physical activity, whether through organized sports or informal activities. Although traditionally women were less likely to be competitive athletes, the number of American high school athletes who identify as female has increased more than tenfold over the past five decades. This growth deserves to be supported.
To ensure that children of all genders can safely participate in competitive sports, a consortium of medical organizations have agreed on standardized pre-sport physical screening and examination. The exact rules and regulations differ from state to state, but the primary purpose of a pre-sports physical exam is to allow physicians (or other appropriate clinicians) to identify and then mitigate the potential damage of young people’s sport participation.
The pre-athletic evaluation form used by the Florida High School Athletic Association, and by extension the Palm Beach County School District, includes screening for everything from family history of heart conditions to concussions to depression. and eating disorders. These questions are included for a reason. Competitive athletes of all genders are prone to energy deficiencies, whether due to eating disorders or excessive energy consumption during workouts. This energy deficiency can cause lasting damage, especially in adolescents.
When energy deficiency is accompanied by amenorrhea (absence of periods), it is of particular concern, as metabolic and endocrine side effects can weaken athletes’ bones, increase the risk of stress fractures and increase the risk of osteoporosis at long term. It is therefore medically appropriate to ask athletes about signs of eating disorders, amenorrhea, and other physical danger signs when deciding whether an athlete can train and compete safely. This is also why the screening form also includes four “women only” questions about menstruation.
However, there is a big difference between a doctor or other qualified healthcare professional asking these questions in private, as part of a clinical assessment, and the doctor sharing all the details with third parties.
The fact that some states may share the full physical exam and screening — including information about young athletes’ menstrual cycles — with school districts, state officials, and third-party digital record-keeping companies is, deeply disturbing to me. The restrictions of the post-Dobbs world, the reality of today’s technological world, and the suggestive examples of other instances where these intersections have made women and girls vulnerable could put parents and physicians in an untenable position.
From a purely medical point of view, pre-participation examination forms endorsed by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, the American Orthopedic Society for Sports Medicine and the American Osteopathic Academy of Sports Medicine, state that only the final decision (for example, whether or not a patient is allowed to play sports, and whether there are any restrictions ) must be shared with a school district. They specifically mention that the medical examination and screening questions should remain with the clinician or evaluating physician.
These tips reflect the enormous importance of protecting the confidentiality of the patient-physician relationship. Confidentiality of clinical interviews is important in general, but even more so for adolescents. And reproductive and gynecological care, including discussions about menstruation, are rightly considered even more private than, say, a lung, heart or knee exam.
But my concern about the reported data sharing goes beyond fears of harming the patient-doctor relationship. The current social, political and technological environment creates a perfect storm for this sharing of information to endanger young people in multiple ways.
First, laws regarding reproductive health, gender and abortion are rapidly being rewritten nationwide. In Texas and Oklahoma, those states effectively offer a bounty to anyone who reports a suspected abortion. In other states, being transgender can result in exclusion from organized sports. One could easily imagine a world in which – if school officials or coaches are expected to track an athlete’s menstrual cycle – certain young people would be flagged upstream (with or without precision) for missed periods. For some young people, this report could lead to inappropriate and invasive gynecological examinations. For other young people, it could lead to them and their parents being charged with a crime. And knowing a child’s rules potentially puts schools in a position of responsibility.
Second, the security of a third-party software system (such as that used by the Districts of Florida) is often questionable. While I can’t judge the level of security of any particular piece of software used in Florida, many of us have already discussed our concerns about poorly designed and poorly protected “rule tracking apps.” Cyber-hacking of electronic health records is on the rise. Even the largest and most security-conscious healthcare organizations are at risk, and data from reproductive healthcare organizations has been specifically targeted and shared. Whenever we share menstrual data with a digital app, we also have to worry about it being accessed by people with malicious intent.
I doubt most school systems are prepared for these legal and safety risks.
Finally, as a mother of a teenager (and a former high school athlete, myself), I cringe at the thought of a coach – even with the best of intentions! – monitor a child’s menstrual cycle for signs of missed periods. Even in my state (which protects abortion as health care, but with parental consent), this kind of aftercare would be embarrassing at best and invasive at worst. And my concerns would be much greater if I was in a condition that limits my reproductive rights and those of my children.
I’m glad Palm Beach County has reconsidered this dangerous policy and requested that questions about menstrual history be removed from the Florida Pre-Athletic Evaluation form. Let’s hope the Florida High School Athletic Association listens and does the right thing for the sake of kids, parents, coaches and schools.