Ankylosing Spondylitis and a Proposed Rule in Florida

I am furious, outraged, and all the other negative, angry words one can think of regarding a recent decision of the Florida High School Athletic Association (FHSAA). The sports medicine advisory committee wishes to make  questions about girls' periods mandatory for female student-athletes. If enacted, the FHSAA would require the addition of four questions for all student-athletes who identify as female to be answered. I will get into why I am so angry in a minute but first, a little background.

Optional answers

As in most states, children who play school sports must be examined for physical health by a doctor. This is usually done at a clinic, their doctor's office, or in some cases (in Indiana), school-sponsored events. In Florida, the girl's athletic physical form asks five optional questions already.  These are:

"When a student had their first menstrual period,
When the most recent one was,
How long the interval between their periods typically lasts,
How many they've had in the past year and
The longest interval between periods in the last year."¹

These questions have been on the form for around two decades. The questions are not mandatory.  If a girl or her family wants to answer, they can; if not, they still pass the physical. In Indiana, the form is maintained by the school at least during the sports season, but in most cases, it is part of the permanent health record.

Proposed required answers

Now comes the FHSAA Medical advisory committee. They have proposed that the FHSAA adopt a rule that the following four questions must be answered on the form the doctor signs for all female school athletes participating in FHSAA sanctioned activities.  These are:

"If the student has ever had a period,
The age they had their first period,
The date of their most recent period, and
How many periods they've had in the past year."¹

With you now up to date, my editorial comment:

Those of us who deal with ankylosing spondylitis (AS) know full well that osteoporosis and osteopenia are common among people with AS. We know this because in 2019, our own very adept Health Union Editorial Team published the following information:

"How common is osteoporosis among people with AS? One study found that 21% of people with AS over the age of 50 in their research study met the criteria for osteoporosis, and another 44% had osteopenia - a condition where there is bone loss but not to the degree of osteoporosis. Osteopenia may develop into osteoporosis, and people with osteopenia are at an increased risk of osteoporosis."²

What is one of the top ways to prevent osteoporosis and osteopenia?  According to the National Institute of Health, it is exercise. "Muscles get stronger when we use them.  The same idea applies to bones: the more work they do, the stronger they get. Any physical exercise is great for your kids, but the best ones for their bones are weight-bearing activities like walking, running, hiking, dancing, tennis, basketball, gymnastics, and soccer."³  Or in other words, the kind of exercise promoted in school athletic programs.

Oh, and for the record, in a study conducted in 2011 and updated in 2019, Tenforde and Fredericson found that girls aged 10 to 30 who participated in school sports had greater bone density as they aged and had better health outcomes overall.⁴ The greatest lifelong improvement came for girls who participated in sports between the ages of 10 and 13.⁴

So why am I so angry about this?

The reason is that making these questions mandatory does three things, in my opinion.

First, the mandatory rules will discourage girls from participating in FHSAA activities. The original optional questions pose little issue; these are more suggestions for a girl's doctor discuss menstrual health, which is just fine. If I had a daughter, I hope the doctor would discuss the matter during the physical. But will a teenage girl willingly take a completed form like that to her coach, who is often male? I believe the net result will not be better but fewer athletes.

Second, it places the school in a challenging position of holding exceptionally private and very personal information. Remember who has access to these health forms. The coach, school athletic director, athletic trainer, and the school nurse, at a minimum, have access to the completed form. So, it is not just a school nurse. In the case of a dispute about who can or cannot play a sport, this information will be viewed by ever-increasing numbers of people with a legitimate interest in the issue.

Third, I do not believe requiring this information does anything for the health of female athletes. Suppose, for instance, a girl who has not had her first period by age 15 (commonly thought to be in the upper range of typical) and wants to play a sport. Would the school ban her, or should the school get a doctor's waiver to allow her to play? Here is one further question, what will she and her parents do to enable her to play High School sports? The most typical outcome is that one or both will lie to the doctor. The doctor will not know her period's precise beginning and ending dates or intervals. In short, the ways around the questions are so numerous as to make the mandatory questions almost laughable.

The real target?

Call me a skeptic, but I sense the form modification is an attempt to prohibit transgender girls from playing girls' sports.

I think such a decision is a matter for her doctor, her parents, and herself to work out.

Florida already has a law banning transgender girls from playing girls' sports. I can't entirely agree with the ban on transgender girls playing girls' sports in some respects. But that is not the issue here. The issue at hand is requiring female student-athletes to send in a doctor's statement related to these questions about their period. And for what?

The results will, in my opinion, be a loss of privacy, a loss of truthfulness with the girl's doctor, fewer female student-athletes, and maybe worst of all, a lack of decency in the treatment of female school athletes.

I have a teenage granddaughter. If she had to comply with such a rule, I hope she and her parents would not allow her to play sports.

As a former school administrator, I know the power of sports in keeping kids engaged, improved outcomes in the classroom, and promotion of social engagement. I know Title IX is a terrific equalizer for girls' sports, and I support it entirely. This rule, if enacted, seems like a step backward to me.

That is my opinion. What is yours? Should these five questions be mandatory for girls who wish to participate in FHSAA activities?  I am interested in what you think.