A brief public service announcement

Parents, this one’s for you.

Prudie has a letter in today’s column:

Fifteen years ago, I was new in town and looking for a children’s dentist, and chose the one named “Best of …” in the local paper. When I brought in my then 6-year-old son, the dentist was the only one in the office—no other patients, hygienists, or a receptionist. The dentist suggested giving my child nitrous oxide since he’d had previous dental trauma and was terrified. He also said he didn’t allow parents to accompany the kids during examination and treatment, as this caused kids to cry more. I’ll bet you can see where this is going, but I had several other small children and was relieved I could just stay with them in the waiting room, so I agreed. When they came out, my son seemed confused and unhappy, the dentist was hyper in a weird and creepy way, and he said that my child had won his weekly special gift giveaway and gave him a surprisingly expensive toy. At this point I thought he fit the profile of a child molester and decided to never come back, but I didn’t have enough evidence to do anything. I wondered, How long until I read about him in the newspaper? Well, the day just came. In my local paper was an article about his arrest for possession and distribution of child pornography.  [emphasis added]

This advice is probably totally unnecessary for the overwhelming majority of parents, but just in case I feel compelled to make something plain.  As a pediatrician, the number of times I have ever examined a small child without his or her parents is zero.  Never.  If I enter an exam room to see a preteen patient and find that the parent has ducked out to go to the restroom, I politely say “I’ll come back in a couple of minutes” and leave; I won’t even have a conversation with an unaccompanied child.  Even for my teenage male patients, if they don’t express a preference one way or the other, I will always default on the side of having a parent in the room for an exam.  (The majority of my adolescent male patients prefer to have their parents wait outside, but that decision is always theirs.  And I never examine female patients without a female chaperon in the room with me.)

With the exception of a trauma bay or an operating room, I cannot think of a single instance when it would be appropriate to instruct parents to leave their children alone.  And never when it’s only the doctor (or, in this case, dentist) in the room.  Period.  I want parents in the room, not only to help reassure the child but also for my own protection against any accusation of impropriety.

I have a special place in the boiling tar pits of my heart for medical providers who prey on their patients, and you can add flaming, pointed sticks for those whose patients are children.  I hope the heaviest weights of the legal system fall on the dentist described in the letter.  I would love to believe that my field is free of such people, but I would be a fool to do so.

Anyhow, in the off chance that it helps some parent out there — your child’s medical provider should never ask to be alone with your small child.  If there is some compelling reason for you to separate from your child, there should always be at least one other adult in the room.  A policy of examining children on their own is a gigantic neon warning sign.  I would never agree to such a policy as a parent, and would never refer my patients to such a provider.

31 thoughts on “A brief public service announcement

  1. Oh, God, Thank you Russell.

    When I was 14, I went over the handlebars of my ten speed; going down hill really fast at the time. I broke my upper jaw, seriously damaged my neck, and of course had serious concussion. Being young and strong, the open wounds healed pretty fast. And then it was time to start working with a dentist for small amounts of reconstruction and repair and a partial to replace the teeth I’d left on the road.

    I’d sit in his chair. He’d be drilling and groping my barely-there breasts at the same time.

    At the time, it seemed no big deal. I was actively dealing with a full-fledged pedophile, a little groping seemed mild in comparison. Except for the drill thing going on at the same time. Remembering the effort to control the fight or flight response of sitting in that chair still puts me all on edge to flight; makes every detail vivid. I assume this is a PTSD reaction.

    To this day, I panic when I think of going to the dentist; I’m in that chair, swallowing down the need to get out of it. It’s taken a long time to find a dentist I trust. I told him my history; and out of respect and care, he always has his assistant stay with us while he works on me. He’s a real artist at rebuilding teeth; he’s alleviated a lot of pain I lived in, not because of dental pain, but because of bite alignment. I’m so grateful to him and his assistant, because it’s really easy for me to avoid the care I need to remain healthy due to that overwhelming panic.

    So I thank you, from the bottom of my heart, on behalf of all children who will someday be adult, children who need not face the panic I feel simply because their parents know it’s okay to stay in the room. Thank you.

    • How terribly ghastly. I’m so sorry you went through that.

      One of the upsides in the erosion of the privileges of being a doctor (and yes, there are upsides) is that hopefully that kind of abuse is becoming harder and harder to perpetrate.

      • I’m just really glad to see you make this ‘public service announcement.’

        Because the other option is the sort we see where folks gather round and cover the back of perps. We see so much of this, protect our heros, our elites, or football players, our movie directors.

        Yes, what I went through is ghastly. But from that, comes real joy to hear you speak out. Because we protect children from predators, we protect adults from becoming predators, one best practice at a time.

        Again, thank you.

      • 2 things:

        1.) Russell, thanks a bunch for the PSA. I have to be honest, and maybe I am particularly naive/trusting (which is kind of weird, and not really like me), I might have acted much the same way as the letter-writer if I had my other kid with me; not due to disregard of my child’s well-being, but because it simply might not occur to me that anyone would violate trust and decency in such a way, and I would be appreciative for the brief break to focus on my other child. Which leads me to:

        2.) zic, I am so, so sorry this happened to you. And this leads me to reconsider something that I think Sam alluded to in the recent rape discussions, how we as a society tend sometimes to focus on the “wrong” things – that a doctor (or any adult, or anybody) would do such a thing is almost literally incomprehensible to me. I am sitting here with tears in my eyes, because I know, intellectually, that it does happen, and all the time; but trying to *imagine* such a horrorshow, is almost like you told me that aliens, or Jason in a hockey mask showed up in the room. My mind won’t easily go there; it recoils; this does not compute; this is not reality (but of course, it is).

        Please understand, this is not an indication of disbelief of the *event*; it is an indication of how such an event, and the mindset of someone who would perpetrate such a crime, is just completely outside the lucky person’s frame of reference.

        So when you encounter someone who seems skeptical or disbelieving or is not weighting all the available evidence the same way you do, at least some cases it may not be so much that they disbelieve the *victim or their story*; it’s that they are maybe having trouble *accepting or comprehending the universe in which this event can occur*. It’s sometimes an indication of their sheltered and blessed existence, and of their natural desire to not believe that some people can be even worse than they already thought.

        They may not themselves be bad people; they may be good people who just don’t yet understand how bad some people can be, because they have been blessed enough to never encounter that evil themselves. And in time, with persistent and gentle persuasion, they may be your greatest allies.

        • For my part, it is inconceivable to me that any pediatrician would want to examine a small child on his or her own. (I am excluding that tiny subset who are predators.) It just seems such an obviously terrible idea, I can’t imagine any sensible provider doing it.
        • Thank you, Glyph.

          I just want to point out that while I’m glad you feel sorry, I don’t need sympathy; I couldn’t say what I’ve experienced if I hadn’t, at least on most levels, dealt with it. I understand dealing is ongoing, but the only thing that really puts me back in the moments of despair is the dentist chair.

          I talk about the things that happened because it’s important. I have an obligation to the future to do what I can to minimize future harm. That’s being responsible. If I hide in a closet of shame or fear, there is no good come of my abuse. If I speak out, and most particularly, if I speak to ordinary, good people who don’t comprehend, if I shine a light into the shadows just a bit, then I’m taking the awful and creating good with it. Turning sorrow to joy.

          So please, while I’m glad for the human response of sorrow and sympathy, more important is the welcome to say what happened. Really and truly, that’s what matters most to me. And I think this may be true of most abuse victims — they need room to speak their stories and the listeners to learn from their stories more then they need sorrow at the stories.

          does that make any sense?

          • The sorrow is part of the learning, part of what will remind people, even when they’re not quite in the right frame of mind… (like that hasn’t happened at a doctor’s office, with a sick kid who won’t stop wailing?)
  2. When I was a teen, I had follicular hyperplasia of multiple lymph nodes in the enguinal area. When it came to doctor’s visits, my mom and the nurse would actually leave the room. Of course, there is no way in hell I was going to take my pants off in front of my mom, but I don’t remember anyone asking me. That said, nothing untoward happenned. Of course the paediatrician was an old professor and friend of my parents and there was lots of trust between them. But its creepy knowing that there are people and places where adults cannot be trusted alone with kids.
    • For that kind of visit, I would take my cues from the patient. If he had a parent in the room and wanted him/her to stay, then they would stay. Many of my older patients show up on their own, and quite plainly don’t need/want a parent present. But if there’s any question about their preference, I always ask.
  3. With my own children, I evolved a protocol with the paediatrician. My wife went in with the girls, I went in with the boy.

    I told all my children, as soon as they had learned enough modesty, that we clothed our nakedness because our nudity was rather too beautiful to be shown to just anyone. When I gave this little speech, I had an art book open to the picture of the Vitruvian Man.

    But medical personnel, I said, were a special case, rather like the mechanic who works under the hood of a car. Doctors and nurses, I said, saw many terrible things: wounded people, even the insides of our bodies in surgery. But medical personnel also saw many beautiful things, too: the births of children, the beauty of our bodies as we became adults. There was to be no shame in nudity, especially not before doctors and nurses. And when the time came, I said, there should be no shame in revealing ourselves to our lovers, for the human body is a glorious thing.

    Modesty is one thing, prudery another. I often wonder if America’s prurient obsession with sexuality arises from too much prudishness in our children.

    • Americans start dating in their early teens. I’ve got a 11 year old cousin in the US who openly discusses her crush on Colin Morgan. There is a frank open-ness about one’s own sexuality among american teens that I would definitely not classify as prudish.
  4. This is a good policy.

    How old are your oldest patients? What if you need to ask them a question that they might be embarrassed to answer in front of their parents?

    I started seeing adult doctors when I was in high school. When I was 15, I began experiencing random stomach pains. It turned out to be nothing but when I told my doctor about it, he asked if I had unprotected sex recently. I was a virgin at the time so I answered no but there are probably many 15 year olds who are sexually active. I can see why a doctor would not want to ask this in front of a parent and why a kid would not want to answer honestly in front of a parent.

    • All of my adolescent patients have a confidential portion of their visit, at which time we discuss sensitive topics. If they explicitly request their parents stay, then I don’t force them to go. Usually both patient and parent express understanding and agreement. But this portion of the visit is only for teenage patients, never for a preadolescent.
  5. Conceding from the start that the teacher:student relationship is not wholly analogous to the doctor:patient relationship, I do want to say that knee-jerk speculation, particularly of males in these professions, is problematic. It is certainly practically wise for men to take extra precaution (which the good doctor offers great suggestions for) to protect themselves, but is problematic that these extra precautions are often then used to justify prejudice and fear-mongering.

    I do think a blanket policy of seeing students or patients without their parents or another adult is good reason for suspicion. But any instance of that happening, of a teacher/doctor (again, male in particular) ending up alone with a child or young adult, is not in and of itself a crime and should not be treated like it.

    And, yes, I realize that the numbers seem to indicate that, if victimized by a non-family member, children are more likely to be victimized by a male. But the numbers also indicate that it is far more likely that children are not victimized at all than that they are.

    • I agree that, through happenstance, ending up alone with a kid shouldn’t automatically trigger suspicion. But, conversely, taking obvious and good-faith steps to avoid it are prudent, and create a reassuring environment for patients and providers alike. (To what degree this kind of policy applies to the school setting is beyond my ken.)
      • “But, conversely, taking obvious and good-faith steps to avoid it are prudent, and create a reassuring environment for patients and providers alike.” Agreed.

        A school environment is indeed different, thought common-sense, thoughtfulness, and deliberateness go a long way. That being said, especially when working with young children, there is a degree of unpredictability inherent to the world that makes unilateral policies impossible. As a general rule, I avoid entering the bathroom with a student (our bathroom is small enough that I can pretty much reach any part of it from the threshold). But, there exists a possibility where a child has the sort of emergency that requires me entering the bathroom, out of line-of-sight of other adults, and which delaying to follow proper procedure would be more costly. I imagine there might exist similar scenarios in a doctor’s office, but presume you probably have more overall control of the environment than I do of mine.

        I actually have a post in mind exploring similar issues, based on something I witnessed firsthand, and which I think (but might be dead wrong about) exemplifies the way in which our efforts to protect children may actually be far more costly on the grander scale.

        • A significant difference between the two environments is the degree of physical contact that is permitted/expected. While obviously (particularly in the bathroom setting you mention) a certain degree of sensitive physical contract is part of your job, it is a regular and necessary part of mine. I have to touch my patients as part of performing a diagnostic exam. Plus, my patients are quite frequently disrobed. That this is an expected part of the exam puts an additional onus on me to perform it with scrupulous attention to propriety.

          Whenever I do a genital exam on a small child, I always say something about how I understand that normally strangers aren’t allowed to look at/touch that part of their body, and that the only reason I am is that I am a doctor and that their parent is right there. (I usually point at the parent at that moment to emphasize the importance of their presence.) Parents often thank me for being so explicit about the boundaries, and helping their children understand the exception to the usual rule.

          • That seems like a pretty great way to describe the differences. My children are old enough that I don’t really need to assist in toileting and, if they did need help, I like would have the time to secure the proper protocol. The scenarios I envision involved a fully-clothed-but-curious child getting his leg caught between the toilet and the wall. Really no different than the sort of help I’d offer a child elsewhere in the classroom, but in a more sensitive physical space AND out of line-of-sight.

            And that is a great way to help the child understand the rare and unique circumstances allowing for a deviation from the norm in regards to physical contact of a sensitive area by an adult.

  6. Good advice; very RM 101.

    One of the things I always had to impress upon new clients who dealt with kids was that they actually had two risks to guard against: the risk that someone in their employ would actually do something inappropriate behind closed doors, and the risk that someone might mistakenly assume that someone in their employ had done something inappropriate behind closed doors.

    Either of those situations can actually be equally devastating to a practice, daycare, school or non-profit.

    • Quite so. Even though I think patients and their parents would say that parental presence is there for the protection of the patient, it’s really protection for me. I know quite well that I am absolutely no threat to my patients, and the presence of a parent has no bearing on that. But I want them there so there is no basis for allegations that spring from mistaken assumptions on anyone’s part.
      • I’m an engineer, so professionally I don’t need to think about these issues from the point of view of being protected, but I’m quite conscious of the conflation of gayness and pedophilia in some people’s minds, so I’m on my guard. Ten years ago, when Jason was in France doing PhD research, a teenage girl in the neighborhood started walking past my house on a daily basis. At first she would stare at me, but I’m neighborly, so pretty soon we were waving and saying “Hi.”

        Soon we were talking more, and it turned out she had a lot on her mind that she needed an adult to help her with, and she appeared to think I was her best candidate. We would talk in the front yard a little bit, now and then. One fall evening she showed up with a Radiohead t-shirt and gave it to me (we’d talked about Radiohead); I invited her in to chat automatically, the way I’d do for anyone who arrived at my door, especially in the evening. We had a really long chat, and later, as I was mulling over what we’d discussed, I realized the danger I might have put myself in: I had a 15 year old girl alone in my house for over an hour.

        I called my brother, who was trying for law school and had had some preliminary classes. He advised me never to do that again, and when the girl showed up again the following evening, I told her what my brother had told me–she couldn’t come in to the house alone with me any more. We both knew nothing would happen, but an accusation could come from any of a number of people. So, we always talked on the front porch after that, or she brought a friend along. It was a good lesson for both of us, I think, in understanding the what adults need to do to help kids navigate adolescence, and learning the legal navigation was particularly useful.

        • “…I’m quite conscious of the conflation of gayness and pedophilia in some people’s minds…”

          As a male in early childhood, I have some folks who are more concerned about the risk I pose when they think I’m gay (a common assumption) and I have other folks who are more concerned about the risk I pose when they learn (or assume) I’m not. It’s some bizarre calculus with variables including their child’s gender, their stereotypes of gay men, their paranoia, and their overall craziness.

          • For some reason, this reminds me of an incident in college. I dyed my hair blue like I used to do when I went to college football games. The hair color didn’t come out immediately. The next day I was at a coffeehouse; it was a full house and I ended up sharing a table with a teenage boy. We were mostly doing our own thing, but we happened to be talking to one another when his dad walked in. He got all angry and said that he would *not* let some [anti-gay slur] turn his son gay.

            I was just like “Wow, how many leaps in logic did *that* accusation require?”

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