By Elizabeth Weil, New York Times, March 30, 2012
(Fort Collins Colorado mother)Tracee and Ainsley (her 9-year-old daughter) visited the office of Jared Allomong, an applied kinesiologist. Applied kinesiology is a “healing art” sort of like chiropractic. Practitioners test muscle strength in order to diagnose health problems; it’s a refuge for those skeptical and weary of mainstream medicine.
“So, what brings you here today?” Allomong asked mother and daughter. Tracee stroked Ainsley’s arm and said, wistfully, “Precocious puberty.”
Allomong nodded. “What are the symptoms?”
“Pubic hair, armpit hair, a few pimples around the nose. Some budding.” Tracee gestured with her hands, implying breasts. “The emotional stuff is getting worse, too. Ainsley’s been getting super upset about little things, crying, and she doesn’t know why. I think she’s cycling with me.”
Ainsley closed her eyes, as if to shut out the embarrassment. The ongoing quest to understand why her young body was turning into a woman’s was not one of Ainsley’s favorite pastimes. She preferred torturing her 6-year-old brother and playing school with the neighborhood kids. (Ainsley was always the teacher, and she was very strict.)
“Have you seen Western doctors for this?” Allomong asked.
Tracee laughed. “Yes, many,” she said. “None suggested any course of action. They left us hanging.” She repeated for Allomong what she told me in the car: “They seem to have changed the definition of ‘normal.’ ”
For many parents of early-developing girls, “normal” is a crazy-making word, especially when uttered by a doctor; it implies that the patient, or patient’s mother, should quit being neurotic and accept that not much can be done. Allomong listened intently. He nodded and took notes, asking Tracee detailed questions about her birth-control history and validating her worst fears by mentioning the “extremely high levels” of estrogen-mimicking chemicals in the food and water supply. After about 20 minutes he asked Ainsley to lie on a table. There he performed a lengthy physical exam that involved testing the strength in Ainsley’s arms and legs while she held small glass vials filled with compounds like cortisol, estrogen and sugar. (Kinesiologists believe that weak muscles indicate illness, and that a patient’s muscles will test as weaker when he or she is holding a substance that contributes to health problems.)
Finally, he asked Ainsley to sit up. “It doesn’t test like it’s her own estrogens,” Allomong reported to Tracee, meaning he didn’t think Ainsley’s ovaries were producing too many hormones on their own. “I think it’s xeno-estrogens, from the environment,” he explained. “And I think it’s stress and insulin and sugar.”
“You can’t be more specific?” Tracee asked, pleading. “Like tell me what crap in my house I can get rid of?” Allomong shook his head.
On the ride back to Fort Collins, Tracee tried to cheer herself up thinking about the teenage suffering that Ainsley would avoid. “You know, I was one of those flat-chested girls at age 14, reading, ‘Are You There God? It’s Me, Margaret,’ just praying to get my period. Ainsley won’t have to go through that! When she gets her period, we’re going to have a big old party. And then I’m going to go in the bathroom and cry.”
In the late 1980s, Marcia Herman-Giddens, then a physician’s associate in the pediatric department of the Duke University Medical Center, started noticing that an awful lot of 8- and 9-year-olds in her clinic had sprouted pubic hair and breasts. The medical wisdom, at that time, based on a landmark 1960 study of institutionalized British children, was that puberty began, on average, for girls at age 11. But that was not what Herman-Giddens was seeing. So she started collecting data, eventually leading a study with the American Academy of Pediatrics that sampled 17,000 girls, finding that among white girls, the average age of breast budding was 9.96. Among black girls, it was 8.87.
When Herman-Giddens published these numbers, in 1997 in Pediatrics, she set off a social and endocrinological firestorm. “I had no idea it would be so huge,” Herman-Giddens told me recently. “The Lolita syndrome” — the prurient fascination with the sexuality of young girls — “created a lot of emotional interest. As a feminist, I wish it didn’t.” Along with medical professionals, mothers, worried about their daughters, flocked to Herman-Giddens’s slide shows, gasping as she flashed images of possible culprits: obesity, processed foods, plastics.
Meanwhile, doctors wrote letters to journals criticizing the sample in Herman-Giddens’s study. (She collected data from girls at physicians’ offices, leaving her open to the accusation that it wasn’t random.) Was the age of puberty really dropping? Parents said yes. Leading pediatric endocrinologists said no. The stalemate lasted a dozen years. Then in August 2010, the conflict seemed to resolve. Well-respected researchers at three big institutions — Cincinnati Children’s Hospital, Kaiser Permanente of Northern California and Mount Sinai School of Medicine in New York — published another study in Pediatrics, finding that by age 7, 10 percent of white girls, 23 percent of black girls, 15 percent of Hispanic girls and 2 percent of Asian girls had started developing breasts.
Now most researchers seem to agree on one thing: Breast budding in girls is starting earlier. The debate has shifted to what this means. Puberty, in girls, involves three events: the growth of breasts, the growth of pubic hair and a first period. Typically the changes unfold in that order, and the process takes about two years. But the data show a confounding pattern. While studies have shown that the average age of breast budding has fallen significantly since the 1970s, the average age of first period, or menarche, has remained fairly constant, dropping to only 12.5 from 12.8 years. Why would puberty be starting earlier yet ending more or less at the same time?
To endocrinologists, girls who go through puberty early fall into two camps: girls with diagnosable disorders like central precocious puberty, and girls who simply develop on the early side of the normal curve. But the line between the groups is blurring. “There used to be a discrete gap between normal and abnormal, and there isn’t anymore,” Louise Greenspan, a pediatric endocrinologist and co-author of the August 2010 Pediatrics paper, told me one morning in her office at Kaiser Permanente in San Francisco. Among the few tools available to help distinguish between so-called “normal” and “precocious” puberty are bone-age X-rays. To illustrate how they work, Greenspan pulled out a beautiful old book, Greulich and Pyle’s “Radiographic Atlas of Skeletal Development of the Hand and Wrist,” a standard text for pediatric endocrinologists. Each page showed an X-ray of a hand illustrating “bone age.” The smallest hand was from a newborn baby, the oldest from an adult female. “When a baby is born, there’s all this cartilage,” Greenspan said, pointing to large black gaps surrounding an array of delicate white bones. As the body grows, the pattern of black and white changes. The white bones lengthen, and the black interstices between them, some of which is cartilage, shrink. This process stops at the end of puberty, when the growth plates fuse.
One main risk for girls with true precocious puberty is advanced bone age. Puberty includes a final growth spurt, after which girls mostly stop growing. If that growth spurt starts too early in life, it ends at an early age too, meaning a child will have fewer growing years total. A girl who has her first period at age 10 will stop growing younger and end up shorter than a genetically identical girl who gets her first period at age 13.
That morning one of Greenspan’s patients was a 6½-year-old girl with a bone age of 9. She was the tallest girl in her class at school. She started growing pubic hair at age 4. No one thought her growth curve was normal, not even her doctors. (Eight used to be the age cutoff for normal pubic-hair growth in girls; now it’s as early as 7.) For this girl, Greenspan prescribed a once-a-month shot of the hormone Leuprolide, to halt puberty’s progress. The girl hated the shot. Yet nobody second-guessed the treatment plan. The mismatch between her sexual maturation and her age — and the discomfort that created, for everybody — was just too great.
By contrast, Ainsley was older, and her puberty was progressing more slowly, meaning she wasn’t at much of an increased risk for short stature or breast cancer. (Early periods are associated with breast cancer, though researchers don’t know if the risk stems from greater lifetime exposure to estrogen or a higher lifetime number of menstrual cycles, or perhaps something else, like the age at which a girl has her growth spurt.) In cases of girls Ainsley’s age, Greenspan has been asked by parents to prescribe Leuprolide. But Greenspan says this is a bad idea, because Leuprolide’s possible side effects — including an increased risk of osteoporosis — outweigh the benefits for girls that age. “If you have a normal girl, a girl who’s 8 or 9, there’s a big ethical issue of giving them medicine. Giving them medicine says, ‘Something is wrong with your body,’ as opposed to, ‘This is your body, and let’s all find a way to accept it.’ ”
“I would have a long conversation with her family, show them all the data,” Greenspan continues. Once she has gone through what she calls “the process of normalizing” — a process intended to replace anxiety with statistics — she has rarely had a family continue to insist on puberty-arresting drugs. Indeed, most parents learn to cope with the changes and help their daughters adjust too. One mother described for me buying a drawer full of football shirts, at her third-grade daughter’s request, to hide her maturing body. Another reminded her daughter that it’s O.K. to act her age. “It’s like when you have a really big toddler and people expect the kid to talk in full sentences. People look at my daughter and say, ‘Look at those cheekbones!’ We have to remind her: ‘You may look 12, but you’re 9. It’s O.K. to lose your cool and stomp your feet.’ ”
“We still have a lot to learn about how early puberty affects girls psychologically,” says Paul Kaplowitz, chief of endocrinology at Children’s National Medical Center. “We do know that some girls who start maturing by age 8 progress rapidly and have their first period before age 10, and many parents prefer that we use medications to slow things down. However, many girls do fine if they are simply monitored and their parents are reassured that they will get through it without major problems.”
In some ways early puberty is most straightforward for families like those of the kindergartner on Leuprolide. She has a diagnosis, a treatment plan. In Greenspan’s office, I asked the girl’s father at what age he might choose to take his child off the drugs and let her puberty proceed. He laughed. Then he spoke for most parents when he said, “Would it be bad to say 22?”