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- [00:01]
Dr. Sanjay Gupta
You know, I have to tell you, as a parent, something I think about a lot is how to have real, authentic conversations with my three teenage daughters. It can be hard sometimes. I realize that things are different for their generation. They have smartphones and screens and influencers. There is news that is constantly blaring everywhere. It's a different time and a lot has changed, right down to our biology. Take for instance, puberty. It's one of the most awkward and yet important stages of growing up. But even that has changed. The average start of puberty in the United States now begins at eight years old for girls and nine for boys. Some kids are going through puberty even earlier than that. It also lasts much longer than it did before. For some people, puberty can last for up to a decade. Just think about that. All of this might come as a surprise to you.
- [00:59]
Dr. Kara Natterson
People know a lot about the puberty they went through, but it is not the same now.
- [01:05]
Dr. Sanjay Gupta
That's Dr. Kara Natterson. She's a pediatrician and she's a parent. She's author of the New York Times best selling series for girls called the Care and Keeping of youf. She also has a sequel for boys called Guy Stuff. She's an expert on puberty. So I decided to sit down to talk to her and try and learn. Why are kids going through puberty earlier and is that early puberty really the new norm? I think most importantly for me, as a dad of three teenage girls, what do parents need to know about how to help their children navigate it? I'm Dr. Sanjay Gupta, CNN's chief medical correspondent, and. And this is chasing life. So if you're a parent, and I'm just guessing we're around the same age, because I know you have two college athletes who are teenagers still, I think, or maybe early 20s, and I have three teenagers. So right around that same age, the way that we think about puberty as parents, but even I think as physicians may be totally different than what our kids are going through. You're a pediatrician, so you obviously have updated knowledge. But for me, as just a dad, it's a totally different thing compared to 30, 40, 50 years ago.
- [02:26]
Dr. Kara Natterson
Even up until the late 1990s, we were all taught in medical school that puberty begins around 11 or 11 and a half, and it takes about two, three, four years. It's a sprint and you get through it and it's super awkward and your body changes and then you're done. That was sort of the teaching and the medical school, more detailed teaching was not a Whole lot more detailed it was that the path through puberty were these stages called the Tanner stages. And Tanner looked at breast development, he looked at penile and testicular growth, and he looked at hair growth. And he did these Studies in the 1940s and 50s and 60s in an orphanage outside of London. And that's where he collected all of his data. So five stages, 10, 10 or 1, nothing's happening, you're not in it. 10 or 5, you're totally done. And 2, 3, and 4, that's puberty. Girls go into puberty around age 11. They're earlier kids. There are later kids, but that was about it. And boys around 11 and a half now. And we started to get this knowledge in the late 1990s when a study was published by a doctor of public health named Marcia Herman Giddens. She published a study, 17,000 girls, that showed, nope, it's not 11 anymore, it's 10. And in fact, if you looked at kids according to their race, kids who are black, their average age of pubertal onset was even earlier. We can talk about that study and what that did, but that really rocked the world. And that was more than 25 years ago, by the way. And then more data came out, and Louise Greenspan with others, published data in 2010 that looked to confirm that original data. And it didn't just confirm it, it moved the starting point even further. So starting in 2010, right. Fourteen years ago, we knew that the average age of breast development for a girl fell somewhere between eight and nine in this country. And for boys, the start of puberty looks like testicular and penile growth, which, frankly, most parents have no idea is happening. I did not know was happening in my own house, because it's when boys tend to get private. But that average age is between nine and 10. So that's different. That's two years different from when we were growing up.
- [04:57]
Dr. Sanjay Gupta
So 11, 11 and a half was what? The onset of puberty. That's the age that we all sort of learned, at least when we were in medical school. And now it's become younger, maybe even as young as eight. Is that normal puberty now, or is that considered early onset puberty or early puberty? How do you refer to it?
- [05:18]
Dr. Kara Natterson
I love this question because I think definition of terms is the most important starting place. Right. So eight to nine is an average. Normal can be earlier than eight for some groups of girls. So as a pediatrician, when I was starting in practice in the year 2000, if a kid had secondary sex characteristics, if their Bodies were starting to change. Usually it meant breast development and it happened before age 8. They would come into my office to see me. That was considered atypical or abnormal. Now that post has moved back to seven. So if a kid is younger than seven, they'll come see a pediatrician. But if they're over seven, most advice is that is within the normal range. Oh, and by the way, if they're 12 and nothing has happened, that is also normal. So now wrap your brain around a five or six year spread of normal onset of body changes. That's really hard for everyone to manage. And I'll add one more term that's really important. So puberty in its narrowest definition means the path to sexual maturation. So when you start puberty, you cannot be part of a baby making equation. And when you finish puberty, you can potentially be part of making a baby. That's the definition of puberty very narrowly. The broader definition, as we talked about earlier, is all the other downstream shifts from all of those sex hormones, testosterone and estrogen and progesterone floating around the body and the brain. Mood swings, friendship shifts, shifts in the way kids make decisions.
- [07:22]
Dr. Sanjay Gupta
I think the point is puberty isn't always straightforward. Things that seem like puberty, using that narrow definition might technically not be puberty.
- [07:32]
Dr. Kara Natterson
There's this thing called adrenarche that is caused when the adrenal glands release their hormones, DHEA and dheas and these hormones are cousins of estrogen and testosterone. And when the adrenal glands release these hormones, these hormones tell the body to make more sweat and in certain places to make it with greasier, thicker proteins and to sprout more hair. Some places it's new hair, some places the hair texture and color changes that sweat hair. You can imagine how body odor and pimples are related, right? That is not puberty. That's called adrenarche. It happens around the same time as puberty, but in some kids it can happen much earlier. So a five year old can have pubic hair and they're not in puberty. Or a 15 year old can be well through puberty and have no body odor, no greasiness and no pubic hair growth. It's confusing.
- [08:46]
Dr. Sanjay Gupta
Adrenarche and puberty can be totally disparate in terms of. Is there a relationship at all between the two?
- [08:54]
Dr. Kara Natterson
Yes, because the hormones are all cousins and they can convert forms. So DHEA and DHEAs can convert into. Into testosterone and forms of estrogen. I should add, people always ask about where body weight fits in. And the answer to that is in many bodies that carry extra weight, they have what's called peripheral conversion of these hormones. So DHEA and DHEAs, when they're floating around the body, can convert more easily into the sex hormones, estrogen and testosterone when there's more body fat. Which is one of the bridges that connects this, which is one of the reasons why kids who carry extra body weight tip into puberty, typically a little earlier.
- [09:45]
Dr. Sanjay Gupta
This is fascinating. I mean, the question I think a lot of people will ask, what you're addressing here is why over the last 30, 40, 50 years has puberty become something that is happening younger and younger? I, you know, again, this is just me talking here. I had heard about high body weight being a concern because of, as you say, what the added fat might do. I had also heard about potential environmental factors playing a role here. And I'm curious what your thoughts are on that. But this idea of stress hormones, you know, I think of stress hormones as sort of short acting hormones. The idea that sort of a persistent exposure to high levels, for example, of cortisol could also be a culprit in tipping people into puberty. Earlier I had not considered that.
- [10:38]
Dr. Kara Natterson
Yeah, so cortisol is for sure a short acting hormone. But when your adrenal glands are pumping it out 24, 7, because you're on social media reacting to what you're seeing, or because you're living in a stressful environment where you're expected to be an academic achiever or an athletic achiever or, or if you're living in a stressful environment because you don't know where your next meal is coming from, or you don't know where you're gonna sleep that night. So all of these things are what we call stressors. And by the way, there's no value judgment to be placed on which stressor is more or less important. But now you can see why every kid is exposed to stress, quote, unquote, stress. Right. We love to throw around that term. What does it mean? It means anything that tells your adrenal glands to pump out cortisol. And the stressors are there all the time. They're there all the time. When we went to school, we came home at the end of the day and any dynamic that happened at school was left at school. Maybe someone called us on the corded phone and maybe one of our siblings let us take the call, otherwise they were busy on the corded phone. Right. Now there is round the clock social dynamics, romantic dynamics. Right. But I don't want to demonize this either. I think it's really, really important to be level about all this. I mean, social media, for instance, for sure there's a connection here. But social media has also been shown to save lives, to build community for people who are marginalized and don't have it. It's too easy to be black and white about this. And so I think it's very important for us to recognize the role of stress and stressors, but also to recognize that some of the things we call stressors have huge upsides and huge positive benefits. I would never argue that the ACEs, the Adverse Childhood experiences that cause stress like food insecurity, financial insecurity, housing insecurity, witnessing violence, living in a traumatic situation, there is no upside to any of those stressors. But a lot of these sort of stressors in lives that are less challenged by ACEs have positives and negatives.
- [13:08]
Dr. Sanjay Gupta
Stress in and of itself is not the enemy. It's the relentless nature of stress, I guess is what I'm hearing you say.
- [13:15]
Dr. Kara Natterson
But I don't want to send people sort of screaming for the hills and stressed out because it is not a switch which goes from 0 to 100 with puberty. When we were growing up, the path through puberty was fast. Today, even though it's starting earlier, it is actually happening more slowly. So it's not like an 8 year old wakes up one morning in the body of an 18 year old. It is not what's happening. What is happening is 8 year olds, if they're girls, might be developing breast buds, they might just have breast buds for a while. It is not like they are going to have their full adult breast size immediately. And this is another thing that is layering sort of the confusion and the sense of I don't know how to help the kid in my life. Parents don't know how seriously to take any of this. And there's worry. I mean, it's just, it's a mess. It's a mess of information that is so easily remedied with just some simple facts. So fact one, puberty is starting earlier. Fact two, it's going slower. It's going slower. Girls are getting their period a little bit earlier than they used to, but not three years earlier. It's more like somewhere between three and six months.
- [14:43]
Dr. Sanjay Gupta
What about the racial divide? So when you take all these factors that could potentially be causing puberty to happen sooner, why racial divide?
- [14:51]
Dr. Kara Natterson
Every researcher that I trust is landing at the same conclusion, which it's going to turn out not to be race, it's going to turn out to be zip code. So if you take this explanation of cortisol being at the heart of everything that's going on and you look at the way this country sets up and the socioeconomic divide and the racial divide, you can't argue that the two are not completely overlapped. It's very, very hard to look at the sociologic data and say, oh yes, we can account for racial shifts in puberty separate from zip code, separate socioeconomic shifts and puberty. So it's kids who are more stressed and more under resourced who are entering puberty the soonest. Now everyone's entering sooner on average. The trend line is down because of something you mentioned earlier, which is these amorphous environmental causes. So the way I would describe that bucket is everything we put into and onto our body is impacting our body, right? So it's everything from the toiletries, the cosmetics that we use, the shampoos and cleansers and moisturizers, many, many, many of them contain chemicals in them that disrupt the hormones in our body. They change the way hormones signal. Likewise, the pollution in the air that we breathe impacts the way our bodies work. Right? Everything. The water we're drinking, depending upon what's in it, the food we're eating, what's, you know, antibiotics that are pumped into animals that then end up on grocery shelves. There's tons of data that shows that those antibiotics shift the way our body's immune system works, our inflammatory cascade, we have inflammation as a result that has impacts on these sex hormones. So it's a lot of things coming at us, but it's a reminder that there are some really incredible scientists out there who are trying to figure out what are these lowest common denominator chemicals that are showing up in these various environmental insults, we call them insults, right. That are changing the way the hormones work in our body so that we can get rid of them. And that's really important. And right now, the foods that don't have antibiotics or the toiletries, cosmetics that don't have a whole list of chemical ingredients tend to be more expensive. So, right, we're back to zip code. We're back to the socioeconomic drivers of puberty. So it's complicated.
- [17:35]
Dr. Sanjay Gupta
If you look at the data around the world, do you see differences geographically by country or culture?
- [17:42]
Dr. Kara Natterson
Yes. So net, net puberty everywhere is starting earlier. And we've known this for a long time. And even in very remote areas, we know that puberty is starting earlier. So that's that sort of global phenomenon of what people are putting into and onto their bodies and how chemicals are shifting the path through puberty. But it looks different from country to country and region to region. And the data's kind of all over the map. And in the US we tend to be a little bit on the earlier side. So the data shows our average start of puberty has been consistently at or below the average for the world.
- [18:30]
Dr. Sanjay Gupta
So puberty happening earlier isn't just a thing happening in the United States. This is a global phenomenon. But I think the real question then is just how worried should we be about kids starting to develop earlier in life? And if we are worried, when then should we as parents get involved? We'll be right back.
- [18:54]
Francesca Street
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- [19:59]
Dr. Kara Natterson
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- [20:38]
Dr. Sanjay Gupta
When we talk about blue zones and things like that, places where people eat better, they live longer lives, they have more social connection, you can see the benefit. And the benefit usually is something like Long you live longer, you have a higher health span, things like that. The question that I really sort of struggle with when it comes to puberty is, is puberty starting earlier a bad thing?
- [21:01]
Dr. Kara Natterson
We have no idea. I mean, because we have no data, right? So people ask this all the time. And the answer is we only have about 25, 26 years of evidence that puberty has really started to march earlier. And so the oldest of those kids are just in middle age now, right? Entering middle age. So we don't know. But what we do know is there have been trends through history of when puberty has started earlier and when puberty has started later. We are so sure that earlier puberty is bad. And yet really, if you look back through the lens of history, in cultures or in societies where there was no food available, what did those kids bodies do? Their bodies slowed down their development and puberty happened much later. And it makes great evolutionary sense. The whole point of puberty is to be able to be part of a baby making equation. If your body, if you are a female and your body cannot carry a fetus because you're so nutritionally deprived, you don't have the food you need, you don't have the nutritional resources, well then why would the body try to develop and get itself there? In order to reproduce quickly, there's no rush. So there are times where you look through historical records and the average age of pubertal onset is 16. And that's because in those societies there was a famine. And so I'm not saying earlier puberty is good. I think we have to put everything in context.
- [22:43]
Dr. Sanjay Gupta
But just in terms of mental health risks, I've been reading some about this and how girls starting puberty earlier might come with added mental health risks. Is there evidence of that? And do we know anything for boys as well?
- [22:56]
Dr. Kara Natterson
So for girls the data is pretty clear and it tethers to this early data about early, earlier puberty, earlier body changes, more sexualization, earlier risk for predation. If your body is changing, no one's talking to you about it, or the world thinks it's happening to you too young, so you're not getting informed in a certain way. But then the world is sexualizing you and expects for you to either think like you're older because you look like you're older, or to behave like you're older because you look like you're older. The setup for mental health issues is tremendous, right? Also the sex hormones, whether they are estrogen and progesterone, which govern female puberty or testosterone which governs male puberty. They circle around the brain, they change the way the neurons fire. They change the way moods are expressed. You know, Louise Greenspan says the first sign of puberty is not breast development or penile and testicular growth. It is a slamming door. I love that line. It is absolutely true. And that is where third and fourth grade parents are like, wow, my kid is in puberty. They are slamming the door on me. That is all those hormones rising and falling and coursing through the brain and changing the way the brain feels and the way it reacts. It has to be a setup for mental health issues. If we are not talking about it. I will add, for boys, there has been no study that looks at testosterone and quiet. But I am 100% convinced that when someone finally studies it, we will see that testosterone surges and drops are what cause the silence of tween and teen boys. We know testosterone causes rage, but the other side of that pendulum swing is silence. And it's not that they don't talk, but they talk less, and then they are rewarded for talking less. Or today's generation of parents says, well, that was what I did, and I just shut my door for three years and my parents didn't say anything and it was totally fine. And I emerged out the other end and I'm okay. And that the truth is, that was then, this is now that sign that you see in boys where they just become monosyllabic or grunters. It is painful for parents. It is hormonal, and there are ways through it. There are conversations you can have with your boys. There are ways to pull them out of their shell. They do emerge out the other side, but they do want to be talked to. I swear, they tell us all the time, just because they're not talking a lot doesn't mean that they don't want to be included in the conversation.
- [25:46]
Dr. Sanjay Gupta
This is so fascinating. I mean, I think anyone listening, myself included, is thinking about those teens in their life, whether their own kids or kids, friends, and it tracks. It's so interesting. I mean, it's fascinating. Let me ask you this. So if parents come to you and say that my kid seems to be going through puberty very early, what is the conversation that you'd have with parents?
- [26:10]
Dr. Kara Natterson
So let's start with this. Any adult who thinks the kid in their life is going into puberty and they have a question or a concern, reach out to a healthcare provider. This is really important. What they need to do is they need to have a conversation, and then they need to do a physical exam, and they need to actually look at your kid. I am a pediatrician. I did not examine my own child. I did not know when my son went into puberty. But it was not my job to be his pediatrician and to examine him and to determine that. So I would take him in for his annual checkup, and if there were any concerns in between, I would take him in and it was the pediatrician who had the conversation with him and examined him, and then I could pick up the conversation from there. Pediatricians are trained to ask parents to leave the room by the time a kid is about somewhere 11, 12, 13, 14, they're going to kick the parent out at some point. That's totally appropriate. Then call them up, ask him, or at the end of the visit, pull them aside. Hey, is my kid in puberty or do I need to worry about anything? There are so many ways into the conversation, but hopefully the theme here is coming through that talking about it is the most important thing.
- [27:35]
Dr. Sanjay Gupta
Puberty can, on average starts around eight or nine, but it can be six or seven, you said. So I have a kid. I think they may be going through puberty at a very young age. Should I be worried about that?
- [27:48]
Dr. Kara Natterson
So before age 7 for a girl, before age 8 for a boy, I would say you would want to bring in medical advice. You start seeing changes in the body, you want to bring in a medical thinker. But you've noticed I'm not using the word concerned or worried because there are a lot of red herrings here. There are a lot of things that can look like puberty that aren't puberty.
- [28:13]
Dr. Sanjay Gupta
But if it is happening before that age, what would the pediatrician be thinking?
- [28:17]
Dr. Kara Natterson
They're looking for what's called precocious puberty. And precocious puberty is puberty that's happening sooner than it should. And one of the causes of precocious puberty, which is not common, but it's always on the list for every pediatrician, is a tumor that is growing in the brain that is telling the brain to secrete the hormones called LH and FSH that tip the body into starting puberty. That's the main thing that people are looking for, is a tumor that is causing the hormones to release early. But I hesitate to go down that road because more often than not, the concerns turn out to be not a worry, but a great opportunity for conversation with the pediatrician. Right. So, for instance, if you have a kid who's carrying extra body weight and you think they're Developing breasts, and actually it's just fat tissue. And a doctor can examine them and show that it's just fat tissue and there's no breast tissue. It's still a great opportunity for a conversation about nutrition and wellness.
- [29:24]
Dr. Sanjay Gupta
Right, Right. But what are some of the approaches that you've implemented as a parent with all you've known? When it comes to talking about puberty.
- [29:33]
Dr. Kara Natterson
The best tip I have is what I did with my son. So I have. My oldest is a daughter who is just a talker, but my son was not a talker. And when he went through puberty, he became really not a talker. And that was very hard for me. So the first thing I learned how to do was to sit on the other side of a closed door. So I would sit on the other side of my son's door, and I would knock on the door and I would say, hey, buddy, I'm actually just sitting on the other side of the door, and I would really love to hear what's going on. And I'm gonna be here for about five or ten minutes, and if you wanna talk, I'm just happy to sit here and talk. And it's so funny. We did. My partner, Vanessa and I did a podcast episode with our two sons who were going off to college this month. And there's a part of the podcast where I talk about this with my son. I'm like, do you remember this? And he said, of course I remember it, because it worked. We didn't have to look at each other. We didn't have to. There was no vulnerability. I wasn't. There was no worry. You know, he was so aware of me being worried about everything. Right. And. And there was none of that with a closed door between us. And then eventually the door opened. And then my strategy became. And it is still to this day, my strategy. Knock on the door. Always knock, go in. He was almost invariably sitting at his desk in his chair, and I would go lay down on his bed and look straight up at the ceiling, and I'd be like, hey, dude, how you doing? And he'd start talking. No eye contact. But my laying on his bed and him sitting at his desk with his back to me was a place and a way that we could get into some of our best conversations. That is a way of communicating with a kid that works. Everyone says, do it in the car. Car is great. On a walk. On a walk is great. You're just not making eye contact. So that's what worked for me. And I hope that other people can take that advice because the parents who taught me that, I am forever grateful.
- [31:43]
Dr. Sanjay Gupta
I gotta tell you. Another piece of crucial advice is to just start having these conversations. Just start talking. Have the conversations, the big ones, the small ones, the silly ones, the serious ones. Because you gotta know this, in this day and age, our kids are exposed to a lot early. And some of what they're exposed to, like it or not, is not what any parent would want.
- [32:06]
Dr. Kara Natterson
The average age of first porn viewing in this country is 12.
- [32:12]
Dr. Sanjay Gupta
Really?
- [32:12]
Dr. Kara Natterson
Yeah. Wow. And 15% of 10 year olds have seen it. So if you're not having conversations like this about all of this, smells and feelings and sex and all of it, if you're not having those conversations with the kids in your lives, someone else is. So it's time to get over the awkwardness. Educate yourself. Find your own trusted adult. We always tell kids to find a trusted adult. Adults, find your own trusted adult. You know, bounce things off of them. But start having these conversations. They can be short. You can have many of them over many years. You will mess them up, I promise you. That's okay. Take a do over, come back and say to your kid, you know what? I said that wrong. I want to try again. But it's really, really critical to know that there are information resources out there for them that compete with you. And if you want to be the source of information, it's up to you to do it.
- [33:19]
Dr. Sanjay Gupta
It's up to you to do it. I think that's a really important point. If you're not having the conversation, likely someone else is in some way shape or form better that you do it, that you be the source. Because we owe it to our kids and to ourselves to do better. When talking about things like their bodies, the way they're changing, what's on their minds, and yes, it might be uncomfortable, it might be awkward even, but it's okay. That's what Chasing Life is all about. Doing our best every day, even when it's not easy, but in the hope and the belief that it will make a difference, because it really does. Chasing Life is a production of CNN Audio. Our podcast is produced by Aaron Mathewson, Jennifer Lai, Grace Walker, Lori Galleretta, Jesse Remedios, Sofia Sanchez and Kira Dehring. Andrea Cain is our medical writer. Our senior producer is Dan Bloom. Amanda Seely is our showrunner. Dan Dezulla is our technical director. And the executive producer of CNN Audio is Steve Lichti, with support from Jamis Andrest, John Dianora, Haley Thomas, Alex Manasseri, Robert Mathers, Lainey Steinhart, Nicole Pessarou and Lisa Namoro. Special thanks to Ben Tinker and Nadia Kunang of CNN Health and Katie Hinman.
- [34:50]
Francesca Street
There's a reason the Sleep Number Smart bed is the number one best bed for couples. It's because you can each choose what's right for you whenever you like. Firmer or softer on either side. Sleep Number does that one side cooler and the other side warmer. Sleep number does that too. You have to feel it to believe it. Sleep better together. Why choose a Sleep Number Smart bed so you can choose your ideal comfort on either side. Sleep Number Smart beds start at $9.99. Prices higher in Alaska and Hawaii. Exclusively at a Sleep Number store near you. See store or sleepnumber.com for details. I'm CNN's Francesca street and this week.
- [35:29]
Dr. Kara Natterson
On our podcast Chance Encounters, we're falling in love while traveling through West Africa's Republic of Benin.
- [35:37]
Francesca Street
It's 2018, and Canadian traveler Rachel Dacoste just landed here.
- [35:43]
Dr. Kara Natterson
Rachel anticipated an important journey of self.
- [35:46]
Francesca Street
Discovery, but she could never have predicted the extent to which this trip would change her life.
- [35:52]
Dr. Kara Natterson
This was destiny. Follow CNN's Chance Encounters wherever you get your podcasts.