Received: by alpheratz.cpm.aca.mmu.ac.uk id EAA17475 (8.6.9/5.3[ref pg@gmsl.co.uk] for cpm.aca.mmu.ac.uk from fmb-majordomo@mmu.ac.uk); Wed, 21 Feb 2001 04:36:25 GMT Subject: Fwd: Doubters Fault Theory Finding Earlier Puberty Date: Tue, 20 Feb 2001 23:33:58 -0500 x-sender: wsmith1@camail2.harvard.edu x-mailer: Claris Emailer 2.0v3, Claritas Est Veritas From: "Wade T.Smith" <wade_smith@harvard.edu> To: "Memetics Discussion List" <memetics@mmu.ac.uk> Content-Type: text/plain; charset="iso-8859-1" Content-transfer-encoding: quoted-printable Message-ID: <20010221043358.AAA15387@camailp.harvard.edu@[205.240.180.124]> Sender: fmb-majordomo@mmu.ac.uk Precedence: bulk Reply-To: memetics@mmu.ac.uk
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- Wade
*******************
Doubters Fault Theory Finding Earlier Puberty
By GINA KOLATA
A widespread belief about the onset of puberty in girls is coming under
vigorous attack, led by a group of medical specialists who say that it is
based on flawed science and that it can have dire medical consequences.
The belief ‹ that girls are now starting puberty as early as age 6 or 7 ‹
began with a single study that critics say has serious problems. The
study led some experts to suggest changes in the guidelines used by
pediatricians in deciding whether girls whose puberty starts early need
to be evaluated by specialists to look for medical problems that might be
the cause.
And it has led parents and social scientists to cast about for
explanations. They have attributed the change to such things as plastics
in the environment or hormones in food or the influence of explicitly
sexual television shows on the development of girls' brains.
But some pediatric endocrinologists are now trying to stop the bandwagon.
"Many of us in the field of pediatric endocrinology believe that it is
premature to conclude that the normal age of puberty is occurring
earlier," eight of them recently wrote in the journal Pediatrics.
The danger, they said, is that if doctors assume that girls who start
developing at 6 or 7 are normal, they might miss serious medical problems
like tumors or genetic disorders that can cause early puberty. Early
puberty can also decrease a girl's ultimate height. And some young girls
have serious psychological and social difficulties when they start
puberty at age 6 or 7.
In addition, some pediatric endocrinologists also worry that doctors who
dismiss such early development as normal might not tell the girls'
parents that there is a safe, though expensive, drug that can temporarily
halt their daughters' sexual development.
Already, these critics say, some parents with legitimate concerns about
their daughters' early development are being brushed off by pediatricians
who believe puberty in the first or second grade is normal.
"You don't just dismiss a child in that age range," said Dr. Laura K.
Bachrach, a pediatrics professor at the Stanford University School of
Medicine. "I think it is potentially medically dangerous."
Dr. Bachrach recalled a 6-year-old who had came to her clinic with pubic
hair and severe acne. The girl, she said, "turned out to have a very
large malignant adrenal tumor."
The problem with the embrace of the early puberty hypothesis, skeptics
like Dr. Bachrach say, is that the science underlying it is questionable.
The single study, they say, does not demonstrate that puberty is starting
earlier than in the past.
In fact, they note, it is well documented that the age of onset of
menstruation, the only date in the continuum of sexual development for
which good data exist, has remained constant for half a century,
occurring at about 12 years and 8 months in white girls and a few months
earlier in black girls.
Some pediatricians, however, still say that the hypothesis of early
puberty rings true to them and that doctors who cling to old notions of
when it should begin are harming girls who are normal, but developing at
today's early age.
"What's worse?" asked Dr. Paul B. Kaplowitz, a pediatric endocrinologist
at the Medical College of Virginia of Virginia Commonwealth University.
Puberty starting at age 6 or 7 and perhaps resulting in a menstrual
period at age 10? "Or," Dr. Kaplowitz added, "going through an exhaustive
endocrinological work-up and monthly injections at $6,000 to $10,000 a
year?"
The issue has now reached the point of an acrid dispute among pediatric
endocrinologists, with the experts on each side barely able to speak
civilly about their opponents.
"A certain amount of dissent can be refreshing," Dr. Kaplowitz said. "But
this is not refreshing."
The early puberty hypothesis emerged when Dr. Marcia E. Herman-Giddens,
working as a physician's assistant in North Carolina, noticed that girls
as young as 7 or 8 were coming in with breasts or pubic hair. Dr.
Herman-Giddens had a hunch that puberty was starting much earlier than
the textbooks said, and proposed a study to investigate.
From July 1992 until September 1993, 225 pediatricians, nurses and
physicians' assistants in 65 private practices in the United States
assessed 17,077 girls aged 3 to 12 who came into their offices. The
girls, they reported, were entering puberty about a year before textbooks
said was normal. Black girls began developing breasts at an average age
of 8.87 and pubic hair at an average age of 8.78. For white girls, the
average ages were 9.96 years for breasts and 10.51 years for pubic hair.
With lower average ages for the onset of puberty, the lower end of the
normal age range was also pushed back, to age 6 for black girls and age 7
for white girls. Many textbooks said the criteria for premature puberty,
based on past experiences in finding girls with medical problems, were
signs of sexual development before age 8 in blacks or whites.
But the average age at menstruation in Dr. Herman-Giddens's study was
about the same as the textbooks said. Dr. Herman-Giddens, an adjunct
professor at the University of North Carolina whose degree is in public
health, was not surprised by the results.
"Everywhere I go," she said, "teachers, parents, everybody, says girls
are starting to go through puberty earlier."
In 1997, her study was published in the journal Pediatrics. And the furor
began.
Some pediatrics professors, like Dr. Melvin M. Grumbach of the University
of California at San Francisco, praised the study, saying in an
interview, "This is an incredible piece of work."
Dr. Grumbach immediately incorporated it into a chapter he wrote on
puberty for the 1998 edition of a major textbook, "Williams Textbook of
Endocrinology."
Others responded with disbelief.
"I thought the study was scientifically flawed," said Dr. Robert L.
Rosenfield, a pediatrics professor at the University of Chicago and the
author of a chapter on female puberty in a leading textbook, "Pediatric
Endocrinology."
For example, Dr. Rosenfield said, the girls were not randomly selected
but had happened to go to their pediatricians ‹ some, perhaps, because
"their parents were a little bit worried about pubic hair or breast
development."
If that happened, he said, the study would have an over-representation of
girls starting puberty early. And no matter how big the study, he added,
once there is a skewed collection of patients the results will be
distorted.
A second problem was that the health professionals were told to look at,
but not touch, the girls' breasts, making it hard to distinguish breast
development from obesity, critics said. "I can tell you that I see many
chubby girls and I can tell you that it can look like they have breast
tissue," said Dr. Paul Saenger, a pediatric endocrinologist at Albert
Einstein College of Medicine in the Bronx.
Finally, critics said, with no reliable studies from previous years, how
can it be said that girls today are starting puberty earlier?
Dr. Herman-Giddens discounted the possibility that there was an
over-representation of girls whose parents worried about early puberty.
And, she said, the health professionals were taught to distinguish excess
fat from breast tissue.
For Dr. Herman-Giddens, and many others who share her concerns, the
findings pointed to a terrible problem.
"There's something in our lifestyle, our environment," she said. "It's a
serious public health issue, and I think it should be addressed."
It did not take long, some pediatric endocrinologists said, before they
were seeing distraught parents whose doctors had reassured them that it
was normal for their 6-year- olds to start sexual development.
"A patient I saw shortly after the paper had been seen by a family
practitioner," said Dr. Ora H. Pescovitz, a pediatrics professor at the
Indiana University School of Medicine. "She was 7 years old."
The child's doctor had read the paper by Dr. Herman-Giddens and thought
it was "normal for a child that age to have puberty and he did not refer
her," Dr. Pescovitz said.
The girl had a type of brain tumor that caused her early puberty.
One mother in Short Hills, N.J., questioned her pediatrician when her
5-year-old daughter developed oily hair and body odor. But the mother
said that the doctor kept saying there was nothing to worry about.
Two years later, Dr. Maria I. New, chairman of the pediatrics department
at Cornell University's Weill Medical College, found that the child had a
genetic disorder, nonclassical congenital adrenal hyperplasia, which,
left untreated, stops bone growth and can cause acne, baldness and
infertility.
"She lost approximately four inches of adult height," the mother said.
In 1999, the debate was inflamed by an article in Pediatrics, by Dr.
Kaplowitz and Dr. Sharon E. Oberfield, a pediatric endocrinologist at the
Columbia University College of Physicians and Surgeons and approved by a
committee of the pediatric endocrine society. Based on Dr.
Herman-Giddens's data, they said, the guidelines for assessing puberty
should be changed. Now, they said, with few exceptions, the only girls
who need to be evaluated for early puberty are black girls under age 6
and white girls under age 7 who are developing breasts or pubic hair.
Dr. Kaplowitz said the old guidelines encouraged an over-medicalization
of normal development. Parents of healthy girls are being told to give
their child extensive medical tests and drugs to temporarily halt
puberty, he said.
He said he worried that the old guidelines labeled too many girls as
abnormal.
"If we were to use the previous guidelines, about 8 percent of white
girls and 26 percent of blacks would be considered to have precocious
puberty," Dr. Kaplowitz said.
Others pointed out that those estimates assumed that Dr. Herman-
Giddens's figures were correct ‹ and they question her data. Medical
abnormalities are not the only issue, they emphasize, saying that girls
may be unprepared for puberty at such early ages.
"Put yourself in the position of a first grader who is developing breasts
or pubic hair," Dr. Saenger said. "It's not normal."
Increasingly distressed, a group of eight experts, including Dr. Saenger,
Dr. Bachrach, Dr. Pescovitz and Dr. Rosenfield, wrote a letter, published
in Pediatrics last September, saying that girls should be evaluated "when
breast or pubic hair appear before 8 or 9 years of age respectively,
regardless of race."
"If you have a 6-year-old girl, which I have in my practice, and she's
got breast development and she's growing pubic and axillary hair, she
will menstruate," Dr. Bachrach said. "She will have a shortened growing
time. And the other implication is psychosocial distress. These girls
look older but psychologically they are still 6 years old or 7 years old
and they are not ready for it."
Copyright 2001 The New York Times Company
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