Background: Accurate pubertal assessment and Tanner staging are essential for diagnosing precocious or delayed puberty, monitoring growth, and preventing psychosocial harm. However, limited trainee competence may result in misclassification and inappropriate referrals. This study examined educational, structural, and cultural barriers to pubertal-assessment training and identified feasible, evidence-informed strategies for Iran.
Materials and Methods: In this structured critical narrative review, guided by SANRA and the Thomas and Harden thematic synthesis framework, we searched international (PubMed/MEDLINE, Scopus, Web of Science, and ERIC) and Iranian (SID, Magiran, and CIVILICA) databases, plus grey literature, from inception to March 15, 2026. English- and Persian-language studies addressing pubertal-assessment education, Tanner-staging accuracy, examination barriers, or educational interventions were included. Data were synthesized thematically across skill-related, structural, ethical/cultural, and educational domains.
Results: Three themes emerged: (1) Clinical and technical deficits, including overreliance on visual inspection, difficulty distinguishing glandular thelarche from lipomastia in girls with overweight or obesity, and high error rates and poor reliability in Prader orchidometer use; (2) Structural constraints, including high patient volume, limited consultation time, scarce private examination space, and inadequate opportunities for direct observation and feedback; and (3) Ethical and cultural complexities, including adolescent embarrassment, modesty norms, preferences for gender-concordant clinicians, ambiguity regarding adolescent assent and parental consent, and limited use of professional chaperones. Tactile and three-dimensional breast and scrotal simulators, standardized patients, case-based learning, and workplace-based assessments (DOPS, Mini-CEX, and OSCE) improved diagnostic accuracy, tactile discrimination, communication, and clinical decision-making.
Conclusion: Improving pubertal-assessment training in Iran requires staged, simulation-based practice before real-patient contact, culturally congruent chaperone policies, institutionalized adolescent-assent protocols, and structured workplace-based assessments to develop comprehensive, patient-centered clinical competence among pediatric residents.