Florida student athletes have to report all these medical conditions when they register to play for the season.
But all female athletes in the state also are asked to report their history of menstrual periods: When they got their first period, how many weeks pass between periods and when they had their last one, to name a few.
The information is reported on athletes' annual physical form, which they are required to fill out with a physician and turn in to their school's athletic director.
The questions have been put to students across the state for two decades, most often on a written form on paper, but this fall when some districts took the form to a digital platform kept by a third party, parents and doctors began raising red flags.
The forms: Florida student athletes asked to report their menstrual history. Here are the questions
Their concerns have been heightened both by a shifting political landscape criminalizing abortions and scrutinizing transgender athletes and the growing threat to medical privacy in a digital age.
All of the forms — whether paper or digital — are subject to subpoena.
Pediatricians are appalled that sensitive medical information is stored with the school district and that coaches can see it.
"I don’t see why (school districts) need that access to that type of information," said Dr. Michael Haller, a pediatric endocrinologist based in Gainesville.
"It sure as hell will give me pause to fill it out with my kid," he said of his own teenage children.
This year in Palm Beach County, nearly all athlete registration forms were moved online — meaning the athletes' reproductive data is now stored by a third party, a software company launched in September 2021 named Aktivate.
Broward, Hillsborough and Sarasota counties are also rolling out Aktivate in schools, according to Palm Beach County district officials.
But both sides of the political spectrum are troubled by the questions involving menstruation:
Abortion rights advocates who stress reproductive privacy in the wake of the Supreme Court's overturning of Roe v. Wade worry that women's menstrual history may be used to prosecute them if they terminate a pregnancy.
And a vocal contingent of parents want forms to stay offline in the name of their parental rights over their children's data — which they worry about being leaked or sold.
"I think we're all on edge right now," Haller said. He added that he has "very little reason to have faith in our state leadership" to keep data provided to educational institutions private.
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Menstrual history and patient privacy have been cast in a new lightfollowing the Supreme Court's June 24 decision in Dobbs v. Jackson Women's Health Organization, which overturned the constitutional right to have an abortion.
Abortion rights advocates quickly began to share fears that women's social media messages and period tracking data could be used against them.
Those fears materialized in Nebraska this summer when police charged a 41-year-old woman and her teenage daughter with an illegal abortion and burning and burying the daughter's fetus.
Police subpoenaed Facebook messages they say showed the teen's pregnancy was not miscarried as the two first contended: Jessica Burgess told her 17-year-old daughter in a message to take abortion pills that she had obtained to end the teen's 23-week pregnancy, police say.
Abortion in Nebraska is illegal after 20 weeks of gestation.
Burgess and her daughter were charged with a felony for removing, concealing or abandoning a body.
After investigators reviewed the Facebook messages,the prosecutor added a felony charge of illegally performing an abortion. Both women have pleaded not guilty and are awaiting trial.
Online health data tracking has been in the crosshairs before.
In 2020, the Federal Trade Commission filed a complaint against Flo, a free app that tracks users' periods and pregnancy data, after the company shared that information with third parties without limits on how the data could be used.
That violated privacy policies in the EU and the U.S. that require notice, choice and protection of personal data transferred to third parties, The Fort Worth Star Telegram reported.
The company settled with the FTC in January 2021, but that settlement did not include restrictions on what types of data can be subpoenaed or which third parties the app can partner with.
"There’s been a lot of discussion, even at the level of the White House, about how individuals' menstrual history should not be widely shared because it could be used to target them in the case of state regulations on abortions," said Joan Waitkevicz, president of the Palm Beach County Democratic Women’s Club.
Although the nation's health privacy laws, known as HIPAA, do not apply to most schools and school districts, Aktivate's contract says all student information will be kept confidential.
But activists point out that apps that collect medical data are covered by HIPAA only if they are run by medical care providers — leaving many users without protection.
Waitkevicz called it "scandalous and shocking" that student athletes are being asked to share their reproductive history on registration forms.
Abortion is illegal in Florida after 15 weeks of gestation.
Understanding an athlete's history and period frequency helps doctors screen for issues that may affect them long term, according to pediatricians who regularly complete athlete registration forms and even one who helped write it.
"If you’re having infrequent periods, say less than one every three months or fewer than nine periods in a 12-month interval, you're at higher risk for weaker bones because estrogen helps build bone density," said Dr. Chris Koutures, a pediatrician based in Anaheim, Calif., who served on the committee that wrote the national physical form.
"Less frequent menstruation could identify that you’re not getting enough energy," he said.
Pediatricians often screen for menstrual issues to identifythe female athlete triad, a disorder: low energy and eating disorders, irregular periods and low bone density that puts an athlete at risk for fractures, Dr. Rachel Chamberlain wrote in 2018 for the American Family Physician.
Koutures said he sees one or two patients each month in his practice who show signs of female athlete triad disorders.
Physicians also find such a history key to diagnosing conditions that can indicate abnormalities in the uterus or uterine lining, unbalanced hormone levels or a bleeding disorder, Haller said.
But both physicians agreed that an athlete's menstrual history should be kept between the patient and their doctor — not reported to the school district.
"I don’t think it was our intent for this information to be shared with anyone else," Koutures said. "The bottom line for the coach is: 'Are they clear or not?'
The rest of the information is between the athlete and their family."
As some community groups push districts to be more gender inclusive, parents and activists have wondered whether the questions about menstruation could be used to "out" transgender athletes — male athletes who get periods or female athletes who don't.
"It’s anti-choice and the anti-trans politics rolled into one," Waitkevicz said.
But Haller, who works with trans youth in his endocrinology practice, isn't so sure. As long as the form doesn't require the menstruation questions or the athlete to report their sex assigned at birth, it's unlikely to "out" trans athletes, he said.
"If they’re forcing the issue then I would call it anti-trans," Haller said. "That’s probably the better question: Why do they have the questions in the first place?"
The three-page physical evaluation form is standard across all Florida school districts. It's created and reviewed annually by the Florida High School Athletic Association (FHSAA) and its sports medicine advisory committee.
On the first page of the form, athletes are asked to list their contact information and answer 46 questions about their health history. The final five questions are optional for "female athletes only." They deal with the athlete's menstruation history and have been on the form since at least 2002, according to documents provided by the FHSAA.
The form's second page asks the physician to report the athlete's blood pressure, pulse, and vision quality. Then comes the physical examination where the doctor reports any issues with the athlete's lymph nodes, heart, lungs and other major organs.
The form also asks the physician to report any abnormal findings with male athletes' genitalia, although it provides no specifics on what the physician should be looking for.
On the third page, the physician signs off on whether the athlete is cleared for participation in sports. It allows doctors to list precautions or limitations for the athlete.
That final page is what acts as an athlete's golden ticket to practice and play. And it's the only page Dr. Tommy Schechtman, a pediatrician in Palm Beach Gardens and a medical consultant for the district's Exceptional Student Education program, said should be shared with the district.
"I don’t see why a school or an athletic department would need that information," he said of the menstruation-related answers. "The only thing that should be shared is the one-page medical clearance."
Palm Beach County's online platform requires parents to upload the entire form, according to Aktivate and parents who spoke with The Palm Beach Post. Previously, athletes were required to hand in all three pages of the form on paper.
And that's the opposite of the instructions given on the national medical eligibility form.
Koutures, who helped review the national form on behalf of the American Academy of Pediatrics in 2019, pointed out that it includes a disclaimer at the top of the athlete's medical history.
It reads: "This form should be placed into the athlete’s medical file and should not be shared with schools or sports organizations. The Medical Eligibility Form is the only form that should be submitted to a school or sports organization."
No such guidance exists on Florida's form.
Instead, Florida's version directs staff to keep the entire form on file with the school.
Craig Damon, the FHSAA's executive director, said the whole packet is turned over to schools so they can "provide any necessary medical information" to a health care worker who is helping a sick or injured student.
He pointed to a Florida statute that tasks the organization with ensuring all student athletes undergo medical evaluation before trying out, working out, competing or performing with a school sports team.
It goes on to say the "results of such medical evaluation must be provided to the school," although it does not specify which parts of the form are considered results.
The Palm Beach County School District keeps the full medical packets for seven years, the district said.
"The coaches do not review the student-athlete's medical information and they do not reference the forms on a regular basis," the district said in a statement. "The school's Athletic Director only checks the physical form for a doctor's signature and the date of exam to ensure that it is in compliance with state statute."
Dr. Thresia Gambon, a Hialeah-based pediatrician and vice president of the Florida chapter of the American Academy of Pediatrics, said she understands why patients are hesitant to keep a written record of their menstrual history outside their doctor's office.
"People are very private about a lot of different things, and everything is electronic now," she said. "I think at some point, that form needs to be revamped."
But Gambon also said it's important for coaches to know general information about an athlete's health.
"The doctor sees the patient once, but the coach works with these patients on a daily basis for two to four months," she said. "They’re the person who can see if there’s an injury, a problem or a concern."
That rings true for Willie Richardson, head coach for both the boys and girls basketball teams at Royal Palm Beach High School.
Richardson said he used to collect his athletes' paper forms himself and turn them into his school's athletic director. Coaches were encouraged to make copies to reference them during the season, but Richardson said he rarely pulled out a form.
"If we do take the time to get to know the players that we’re working with, we find out a lot more about them," he said. "They say 'Hey coach, you know I have this (medical condition).' They're vocal."
Richardson said he usually hears from parents at the start of the season regarding medical needs for players. That, not the form, helps him keep track of who needs more water breaks, shorter conditioning sessions, access to an inhalers or an Epi-Pen.
Just two months before the start of school, the Palm Beach County School District contracted with Aktivate to bring the whole registration process online for the 2022-23 school year.
Aktivate signeda three-year contractthat will net the company $9,500 each year — just under the $10,000 threshold that requires school board approval — on June 16.
Valerie Miyares, the district's director of athletics, said the district chose the platform after eight months of meetings with coaches and screening the platform.
"The system is both FERPA- and HIPAA-compliant, and provides families with a better level of security than the paper packets being stored in offices or being passed between personnel and locations physically by hand," she said.
The district underscored the system's adherence to both policies, but Aktivate is given special privileges that allows the company to get students' medical history.
The Family Educational Rights and Privacy Act (FERPA), a federal law that protects student privacy, requires schools to have written permission from the parent or student to release any information. But FERPA allows schools to disclose those records, without consent, to parties designated "school officials with legitimate educational interest."
By contract, Aktivate is deemed a school official entitled to receive relevant information to determine students' eligibility to participate in sports teams.
Last month, parents at a school board meeting questioned the security of the system and demanded an alternative.
"I feel you're coercing parents into an agreement with a third-party vendor whose terms and policies I do not agree with. Your policy violates my child's personal medical data (privacy) and I do not agree nor consent," Yvette Avila said Aug. 17. "You're forcing the relinquishing of parental rights over my children."
The following day, the district announced it would allow parents to fill out the forms on paper and submit them.
"We signed an agreement, and we obviously intend to comply with the law," Kutscher said. He added that Aktivate's software offers "far bigger security, by the way, than paper."
But the policy says that all student data is subject to subpoena and government enforcement proceedings. Aktivate can also share data with researchers and business partners without any identifying characteristics such as athletes' names and locations.
Micah Green, chief legal counsel at Aktivate, provided a few examples of when Aktivate could use student data:
When asked about sharing or analyzing menstrual data collected from physical registration forms, Green said the company has "never thought about that before."
Katherine Kokal is a journalist covering education for The Palm Beach Post. You can reach her at firstname.lastname@example.org. Help support our work, subscribe today.