Adolescent development
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7486.301 (Published 03 February 2005) Cite this as: BMJ 2005;330:301
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Dear Sir,
In your article (1), the authors have highlighted their supposedly
“important messages” in blue; there does not seem to be much thinking
involved in crafting two of them, at least. The first one reads as
follows:
Whereas puberty and cognitive development are largely biologically
determined, the greater part of psychological and social development will
depend on environmental and socio-cultural influences. In non-Western
cultures, the social and psychological domains may be markedly truncated
The reader will know that so-called “Western culture” is not uniform,
and even if it WAS uniform, there are at most only 1 billion people living
in “Western countries”; if the remaining 5 billion people living in non-
Western cultures are “deprived” from acquiring specific “environmental and
socio-cultural influences” such as domestic violence, being raised in a
single-parent family, sexualisation of everyday life, recreational drug-
taking, relentless consumerism, binge-drinking, teenage pregnancies etc,
it might in some ways be all for the better that their “social and
psychological domain” is “truncated”. It is highly presumptuous to imply
that non-Western cultures are inferior, and that five-sixths of the
world’s adolescent population may experience “poorer” psychosocial
development.
Another blue box reads as follows:
It may be hard to remember our childhood accurately, but few people
forget their adolescence
Highlighting a platitude in blue does not transform it into wisdom!
It would be very hard to find someone who would ever argue that the memory
of a 4-year old is the same as that of a 14-year old. It would be best if
this box were deleted altogether in the book edition of the ABC of
Adolescence; otherwise, the reader might think that the authors are
rounding up the word count by adding on such elementary observations.
It seems that the peer reviewers and the editors have again been
dozing off; worse still for the BMJ readers, if this is not the case.
(1) Christie D, Viner R. Adolescent Development.BMJ 2005; 330: 301-
304
Competing interests:
None declared
Competing interests: No competing interests
Delayed Puberty: if in doubt procrastinate?
Dear Sir,
The authors correctly state that delayed puberty in boys "can be
quite distressing but is almost always a normal variant". However, they
then suggest that "boys aged 15 or over with a testicular volume of 4 ml
or more can be reassured that puberty is beginning" and, therefore by
inference, do not require referral to a Paediatric Endocrinologist. This
advice is potentially misleading and could lead to adverse patient
outcomes for the reasons outlined below.
Constitutional delay in growth and puberty (CDGP) can result in a
significant psychosocial and skeletal consequences if left untreated, for
all that it is a "normal variant" (1,2,3). To deny a teenage boy with no
external signs of puberty the opportunity to choose low-dose androgen
therapy until he was well over 15 years of age would be remarkably
conservative practice by today's standards. Indeed, given the length of
time that would necessarily elapse before triggering the specialist
referral, any primary care physician following these recommendations might
well find him/herself referring the patient to an adult-, rather than a
paediatric Endocrinologist!
A testicular volume of 4ml is well within the range found in males with
irreversible hypogonadotrophic hypogonadism (IHH) and therefore by no
means necessarily indicates "that puberty is beginning". Indeed a
significant proportion of IHH males do initiate puberty, but fail to
progress beyond the very early stages (4,5).
Even assuming lower thresholds for age and/or testicular size, collection
of other information is vital to the timing of specialist referral. For
instance, a history of bilateral cryporchidism and/or anosmia should
prompt referral at a much earlier age (4). Nor does a family history of
pubertal delay necessarily support a diagnosis of CDGP as there is also a
high prevalence of simple pubertal delay in 1st degree relatives of IHH
patients (5).
I would commend the Authors and other readers to www.Kallmanns.org. A
recurring theme in the personal stories posted on this site by IHH men is
of just how difficult it was for them as teenagers to screw up the courage
to go and see their family doctor about a lack of secondary sexual
characteristics. On being told "not to worry, because it's only pubertal
delay", many of them felt (or were made to feel) so crushed and/or foolish
that they then put off seeing a doctor for years or, in some cases, even
decades.
Yours faithfully,
Dr Richard Quinton MA MD FRCP
1. Skuse D. 1987 The psychological consequences of being small. J
Child Psychol Psychiatry. 28:641-650.
2. Crowne EC, Shalet SM, Wallace WH, Eminson DM, Price DA. 1990 Final
height in boys with untreated constitutional delay in growth and puberty.
Arch Dis Child. 65:1109-1112.
3. Finkelstein JS, Klibanski A & Neer RM. 1996 A longitudinal
evaluation of bone mineral density in adult men with histories of delayed
puberty. J Clin Endocrinol Metab. 81:1152-1155.
4. Quinton R, Duke VM, Robertson A, Kirk JMW, Matfin G, de Zoysa PA,
Azcona C, MacColl GS, Jacobs HS, Conway GS, Besser GM, Stanhope RG &
Bouloux P-MG. 2001 Idiopathic gonadotrophin deficiency: genetic questions
addressed through phenotypic characterisation. Clinical Endocrinology.
55:163-174.
5. Pitteloud N, Hayes FJ, Boepple PA, DeCruz S, Seminara SB,
MacLaughlin DT, Crowley WF Jr. 2002 The role of prior pubertal
development, biochemical markers of testicular maturation, and genetics in
elucidating the phenotypic heterogeneity of idiopathic hypogonadotropic
hypogonadism. J Clin Endocrinol Metab. 87:152-160.
Competing interests:
None declared
Competing interests: No competing interests