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Treating Boys and Girls Differently
From: Columbia University
| By:
George Lazarus |
EDITOR'S INTRODUCTION |
For George Lazarus, M.D., the concept of gender-specific medicine seems painfully obvious. As a pediatrician, Lazarus has watched numerous boys and girls develop and respond to disease differently from their infancy through puberty. From the gender determinism of sex-linked diseases such as hemophilia, to specific manifestations of diseases such as attention deficit disorder, to varying rates of illnesses such as eating disorders, boys and girls are not the same. In his 24 years of practice, Lazarus has observed parents seeking to deny such gender differences in order to promote equal rights for their daughters. |
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| George Lazarus | |
 hen Dr. Marianne Legato, the founder and director of Columbia University's Partnership for Women's Health, asked me to speak on gender differences in medicine, it almost seemed like an oxymoron. Pediatricians recognize from the beginning that boys and girls are different. If somebody had told me when I was a child that as a grown-up professional I would tell a group of equally grown-up professionals that boys and girls were different, I would have thought it was some kind of a joke. Of course boys and girls are different. It seems silly to have to prove that boys and girls are different. |
Gender equality versus biological differences
About a generation ago, I started to see parents who wanted to deny that boys and girls were different, because traditionally boys had access to all the opportunities. Boys grew up to be CEOs and powerful professionals, while girls became housewives. People wanted to see that change. They wanted to see equal opportunity for girls. Parents felt that one way to give girls a better future was to start treating boys and girls equally from birth--denying their differences. |
I want to tell you a true story about a family that decided to raise their daughter the same way they would raise a son. By growing up like a boy, she would have the kinds of opportunities that seem to be reserved for boys. They decided it wasn't right that boys were given trucks and guns to play with and girls were given dolls. So, instead of dolls, they gave their daughter four toy trucks on her birthday. She went up to her room to play with her trucks. After a while it became very quiet in her room, so they decided to see what was happening. When they went up to the girl's bedroom, the door was shut. They opened the door and the room was dark. She had the four trucks on her bed, half on the pillow and half off the pillow. The blanket of the bed was pulled up to cover half of the trucks. As they walked into the room, the girl said, "Shhhhhh... They're sleeping." |
Girls and boys behave differently and they think differently. While ensuring that women can grow up to become professionals and CEOs is certainly a worthwhile goal, we will not achieve that goal by denying the difference between boys and girls. Pediatricians don't deny the difference. It's just something that's obvious from the very beginning. When you take your children to the pediatrician, you'll notice that we have growth charts for boys and growth charts for girls. They're not the same. The percentiles are not the same. Their size is different, to begin with. |
The differing biology of girls and boys
Some very blatant biological differences exist between boys and girls. Sex-linked differences are, of course, the most obvious. We don't worry about girls having hemophilia--it appears only in boys, since it is a sex-linked disease. There are also diseases that remain limited exclusively to girls, for instance Turner's syndrome. (Turner's syndrome is a sex aberration in which the chromosome complement includes only one sex chromosome, an X.) |
In infants, we see diseases that progress differently by gender; for example, adrenogenital syndrome. An abnormality of the adrenal gland, adrenogenital syndrome can result in the death of an infant due to adrenal insufficiency. It is much more likely to be spotted in a girl, because the genitals will be abnormal--resembling either the genitals of a male or some sort of intersex. It is more likely to be missed in a boy, because the genitals will look normal. Adrenogenital syndrome can cause death if not picked up quickly enough. Pediatricians take into account these differences when looking for diseases in boys and girls. |
Attention deficit disorder
One of the most common behavioral problems that pediatricians and parents deal with is attention deficit disorder. Everyone knows that we have too many children taking Ritalin for attention deficit disorder. Ritalin clearly helps some of these children, but others I suspect are on the drug inappropriately. If you speak to child neurologists, they'll tell you that the ratio of referrals for attention deficit disorder stands at six boys to every girl. In fact, the best studies indicate that boys develop or have attention deficit disorder twice as often as girls. |
So why are boys brought in for treatment or evaluation six times more frequently than girls? Because the boy who has attention deficit disorder becomes a hyperactive pain in the neck. He drives everyone crazy, including his teachers and his parents, so they run to the pediatrician and then perhaps to the neurologist. They need help because they can't control this kid. |
The girl who has attention deficit disorder is just as disorganized. She doesn't have a clue what's going on in the class, but she just sits there very quietly and behaves herself. Girls with attention deficit disorder often don't come to medical attention until they start failing when they reach junior high school. Until then, if they're quiet and they're nice and they behave, nobody notices any problem. |
Puberty
Pediatricians take care of children at least through adolescence. Most of us now follow children through into young adulthood. Puberty occurs earlier in girls. This is no mystery. If you think back to the fifth or sixth grade, the girls towered over all of the boys. Girls grow up sooner. They also grow up differently. Traditionally, puberty is considered premature in a girl if the first sign occurs before the age of 8. Some suggestion now exists that we should instead consider puberty premature if it occurs before age 7. We are starting to see significant numbers of girls develop at age 7. African-American girls may even begin puberty at age 6, which is startling. |
For boys, puberty before the age of 9 is clearly pathological. You have to find out the causes of early puberty in a boy, because it may stem from something very serious, such as a brain tumor. The onset of puberty clearly differs for boys and girls. |
How puberty occurs also differs by gender. As soon as girls enter puberty they experience a major growth spurt. Once the breasts start to develop, girls shoot up in height. That's why in the fifth and sixth grades girls get very tall. They'll probably reach their adult height by the time they're 14 or 15 years old, or two years after their first menstrual period. On average, girls get their first period at 13 years old. |
Boys first start to grow at age 15. Why? Not only do they enter puberty a little bit later--around seventh grade--but they don't have their growth spurt until the second half of puberty. Nobody knows when boys enter early puberty, because the changes remain in parts of their bodies not exposed to public view. As soon as a girl enters puberty, her breasts start to develop, which is obvious to the entire world. Boys go through puberty differently and have different behavioral responses. |
Depression
There are innumerable behavioral differences between boys and girls. Depression is equally common in boys and girls before puberty. After puberty, however, depression becomes more common in girls. You see many more suicide attempts in teenage girls than in boys, but boys have a more successful suicide rate. Why? Boys who kill themselves are more likely to use guns or to hang themselves. Girls are more likely to take pills, which gives you a better chance of intervening before death occurs. |
Eating disorders
Obesity is more common in girls. Again, this difference shows up after puberty. It's clearly a biological issue and not just a behavioral issue. Girls almost have a monopoly on eating disorders. They account for 90 percent of the patients with eating disorders. Dealing with anorexia nervosa and bulimia is a nightmare--it's a tremendous problem. |
Osteoporosis
Eating disorders also have great implications in terms of preventing osteoporosis, a major problem in adult women. To prevent osteoporosis, we have to start with the pediatric age group. Bone development occurs so rapidly in puberty that we have to start with girls, in order for them to have adequate calcium as women. |
Health and young mothers
As pediatricians, we not only interact with our own patients through adolescence and into early adulthood, we also have a chance to deal with the mothers of our newer patients. For those of us who have been around for a number of years, it's always fun when the mother of a new patient is a former patient herself. We often have the chance to talk to young women having children about their own health. |
Young mothers often ask me, "Should I breast-feed my child? Is there an advantage to the child from breast-feeding?" I like to tell them, "There is evidence about some advantages to breast-feeding for the child. But probably more important is to consider the advantage of breast-feeding to you, the mother, in terms of decreasing the chance of developing breast cancer later in life." My obstetrics and gynecology colleagues know the statistics better than I, but there is evidence that breast-feeding provides some degree of protection against breast cancer. We also know that if we can get all women of childbearing age to take small doses of folic acid we can significantly decrease the incidence of spina bifida--a severe abnormality of the spinal cord which may cause lifelong paralysis. |
The time to teach these health lessons is in adolescence. The opportunity to reinforce that message for young mothers rests with the pediatrician as well as with the obstetrician and gynecologist. |
Quality care through gender-based medicine
Those are just a few examples of how biology differs for boys and girls. We're not totally different animals. There are a lot of similarities. But enough differences exist that it certainly makes a significant difference whether you're dealing medically with a boy or a girl. |
For me, the idea that boys and girls are different seems something of an oxymoron, but I guess it's not for everyone. As adults, we have to relearn a lesson that seemed obvious when we were children. We are different. We should not deny those differences but rather study them and learn to appreciate them. We need to learn to take care of people appropriately by recognizing these differences. |
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