Dr. Qaadri

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Testosterone, Estrogen and Early Puberty

By Dr. Shafiq Qaadri, MD

TORONTO -- Teens before their time, little women, early bloomers, children in women's bodies: They are girls aged 10 and younger who, between playing with dolls and learning their times-tables, are entering puberty.

"My 10-year-old granddaughter asked me what a clitoris is," says a retired Toronto-area physician. "What am I supposed to say?" More and more unsuspecting adults are being startled by such questions.

While doctors and researchers try to discover the causes of early puberty, the girls, their parents and peers must deal with the attention and responsibility that physical maturation brings. Some parents, however, are not willing to let their children blossom too early: They are using medication to slow nature.

On average, girls now start developing sexual characteristics at age 10 (some girls much earlier). This means they are maturing two to three years earlier than their mother's generation, says Dr. Marcia Herman-Giddens, a pediatric researcher at the University of North Carolina who discovered the trend in 1997. Dr. Herman-Giddens calls the finding "shocking and distressing." (Boys, on the other hand, will still be boys, as research shows there is little, if any, male pubertal acceleration.)

The transition to adulthood -- spread over several years -- involves many changes: breast development, pubic and underarm hair, widening thighs and hips, a growth spurt, mood swings, concerns about self-image, a new awareness of boys and, finally, menstruation.

Dealing with such myriad changes would be a challenge at any age, but is especially so for primary-school girls. "This is the age when youngsters are being taught how many quarters are in a dollar," says Diane Zuckerman, a child psychologist with the National Centre for Policy Research for Women and Families. "These are young kids."

There is no single cause of early puberty, and intense research is under way to discover the exact mechanisms. Many factors have been implicated -- everything from the power of suggestive imagery to childhood obesity to hormone-treated meat to living with a stepfather.

Certainly society promotes sexualized behaviour: Young girls dress, groom, pierce, perfume, flirt and experiment like adults. Consider this advice from a magazine directed at preteens and teens: "Want to spice up a kiss? Give your boyfriend a piece of candy. When he puts it in his mouth, go in for a kiss and steal it back . . . Tell him if he wants it back, he'll have to come and get it!"

A more hidden but insidious cause of early puberty is the many environmental toxins, which act as hormone-disruptors. For example, the U.S. Food and Drug Administration only regulates products that contain prescription quantities of the female sex-hormone estrogen. Products containing lower amounts of estrogens -- less than 10,000 International Units per ounce -- are unregulated. Yet these products do have active feminizing effects on people.

It is for this reason -- stealth estrogens -- that the European Union has banned the import of most North American beef, which is hormone-treated. This ban is now a major dispute under negotiation at the World Trade Organization.

And the number of products that contain estrogen-like chemicals is growing: sunscreens, nail polish, plastic toys and baby bottles, pesticides, shampoos and hair straighteners, meat additives and fillings in teeth. A new term is now current in research literature: HCPs, hormone-containing products.

While some consumer products might contain minute amounts of estrogens, if any at all, others contain quantities usually available only by prescription. Some shampoos, for example, contain almost the same amount of hormone as do low-dose estrogen patches, which are used for hormone-replacement therapy in postmenopausal women.

In Our Stolen Future, Dr. John Myers of the United Nations highlighted the toxic effects of some of the estimated 70,000 chemicals in commercial use. Dr. Myers is alarmed, but not surprised, about such hormone-disruption, especially as growing kids have prolonged, regular exposure to various environmental contaminants.

Another remarkable finding was published by New Zealand psychologist Dr. Bruce Ellis: Girls who live with a stepfather tend to go through puberty early. This is the "strange male theory" -- apparently the child picks up chemical cues, sensing the man's natural scents, known as pheromones, and this musk-like fragrance promotes early maturation. The "real" dad has a calming effect -- if the biological father is present and regularly interacts with his daughter, the girl picks up cues to delay puberty.

Evolutionary theorists suggest that in the presence of a strange male, a girl's body accelerates its growth so as to be independent earlier and to deal better with stress.

But as a society, are we ready for these adult kids?

Bodily changes, for example, can be troublesome for a young mind. "Boys make fun of me," says a maturing 11-year-old girl, who is already weight-conscious and prone to fad diets. "In gym, they laugh at my bouncing chest . . . and try to snap my bra straps."

To help adolescents avoid possible depression, social isolation and loss of self-esteem, educators such as Lynn Madaras, author of The What's Happening to My Body? Book for Girls, recommend "positive parenting," which includes open, nurturing and age-appropriate discussion.

"Start by talking about the physical [and emotional] changes your daughter is going through . . . without going into details about sexual relations," says Dr. Helen Egger, a child psychiatrist at Duke University. Studies show kids appreciate such discussion at home, yet many young girls receive little instruction, and end up seeking random advice from their peers.

"My mother never mentioned the changes that go along with puberty," says Linda Gresko, who recalls getting her period at age 11.

Yet many teachers and public-health officials don't want to wait for parents to initiate discussion, and are calling for explicit sexual education for ever-younger grade-school students. Asked if he and his classmates were ready for detailed sex-ed, one 13-year-old boy crudely replied: "Why not? Old enough to bleed, old enough to breed."

This places doctors in a novel dilemma, as younger and younger patients seek counselling about sexual matters.

Kids are visiting clinics with their queries: "Doctor," asks a 12-year-old, "I have a friend who was asking me, 'If a boy comes on your stomach, can you still get pregnant?' "

"A friend?" I inquire.

"Yeah, well. Okay, it's for me. But don't tell my parents."

When a child asks about going on the birth-control pill, what should the doctor do? There aren't any firm guidelines any more. Previously, if a person was younger than 16, it was understood that they required parental authorization for any prescription. Now, a child can start oral contraceptives at will, yet would require parental consent for a school field-trip.

How old should a child be for their first pelvic examination? When should doctors begin serious counselling about birth control, sexually transmitted diseases and the risk of pregnancy?

Watching children adolescing before their eyes, many parents are going beyond talk-therapy, guidance and easy reassurance. They are reacting militantly, as they feel their children know too much already. Wanting to pace the rush to maturity, some parents are asking: "Can't you slow my daughter down?" And doctors are obliging these parents with Lupron, a hormone-suppressing injection which delays puberty.

Dr. Floyd Cullen, a professor of pediatrics at the University of California, Irvine, advocates "preserving the childhood years . . . [if she's] not ready to bear childhood in an adult body."

Parents seek puberty-delaying medications for different reasons: Some mourn the loss of innocence, others fear the possibility of sexual attention -- even predation -- of their daughters.

"I see the way guys look at her," says one mother about her 12-year-old. "I'm afraid someone's going to try to hit on her." These parents have legitimized in their own minds the medical suppression of their child's growth pace, calling timeout on their child's biological clock. Doctors also point to a possible link between early puberty and breast cancer in later life, further justifying the prescribing of these growth-delaying therapies.

But who is the beneficiary of treatment: the non-maturing child or the insecure parents? And is this a legitimate use of medication, or another cosmetic lifestyle modification? There are no easy answers, and each family must come to its own decision on a case-by-case basis.

Major legislative changes regarding the use of biologically active environmental estrogens are expected, especially as the effects only show up in the next generation.

Meanwhile, empathy, understanding and open channels of communication are the best strategies to help your girls and boys become healthy, secure and emotionally balanced adults -- at whatever tempo nature sets.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca

A primer

Puberty in girls
Breast budding and enlargement
Hair in the pubic area and underarms
Widening thighs and hips
Growth spurt
Acne
Mood swings
Concerns about self-image
A new awareness of boys
Menstruation

Puberty in boys
Enlargement of the testes, scrotum and penis
Pubic, underarm and facial hair
A deeper voice
Growth spurt
Acne
Concerns about self-image
A new awareness of girls

Causes of early puberty in girls:
Genetic factors
Sexualized, graphic material in the mass media, particularly the Internet
Obesity: fat cells act as estrogen factories
Environmental contaminants: estrogen-like chemicals found in sunscreens, nail polish, plastics, pesticides and hormone-treated beef
Living with an unrelated adult male: a young girl unconsciously senses the man's pheromones, the body's natural scents, which stimulate early puberty; if the biological father is present, his pheromones delay his own daughter's puberty.
Race: African-American girls have the most accelerated development.

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