Background: Accurate pubertal assessment and Tanner staging are essential for diagnosing precocious or delayed puberty, monitoring growth, and preventing psychosocial harm. However, trainees often have inadequate clinical competence, causing misclassification and inappropriate referrals. This study examined educational, structural, and cultural barriers to pubertal-assessment training and identified feasible, evidence-based strategies tailored to Iran.

Methods: In this structured critical narrative review, guided by the Scale for the Assessment of Narrative Review Articles (SANRA) and the Thomas and Harden thematic synthesis framework, we searched international (PubMed/MEDLINE, Scopus, Web of Science, ERIC) and Iranian (SID, Magiran, and CIVILICA) databases, plus grey literature, from inception to March 31, 2026, in English and Persian. We included studies evaluating pubertal assessment education, Tanner staging accuracy, barriers to adolescent examinations, and educational interventions. Data were synthesized using narrative thematic synthesis across skill-related, structural, ethical/cultural, and educational domains.

Results: Three themes emerged: (1) Clinical/technical deficits: overreliance on visual inspection, difficulty distinguishing glandular thelarche from lipomastia in overweight girls, and high error/poor reliability in Prader orchidometer use; (2) Structural constraints: high patient volume, limited consultation time, scarce private examination space, and inadequate direct observation/feedback; (3) Ethical/cultural complexities: adolescent embarrassment, modesty norms, gender-concordance preferences, ambiguity between adolescent assent and parental consent, and limited professional chaperone practices. Tactile/3D breast and scrotal simulators, standardized patients, case-based learning, and workplace-based assessments (DOPS, Mini-CEX, OSCE) improved diagnostic accuracy, tactile discrimination, communication, and decision-making.

Conclusion: Improving pubertal assessment training in Iran requires shifting from didactic, atlas-based teaching to staged, simulation-based deliberate practice before real-patient contact; establishing culturally congruent chaperone policies; institutionalizing adolescent assent protocols; and implementing structured workplace-based assessments to build comprehensive, patient-centered competence.