470 Adolescent Health
peers, and (e) strengthening relationships with family and
female friends.
Body Image
Considerable evidence indicates that American girls in gen-
eral are less satis“ed with their bodies than are boys (with
weight satisfaction being the largest gap) and that boys• satis-
faction increases with age while girls• does not. In fact,
gender differences in depression were virtually eliminated
by controlling for negative body image and low self-esteem
in a study of White high school students (Allgood-Merten,
Lewinsohn, & Hops, 1990). In general, body image affects
overall self-image and self-esteem, especially for girls. A
report by the American Association of University Women
(AAUW, 1992) found that con“dence in •the way I lookŽ
was the most important contributor to self-worth among
White schoolgirls whereas boys more often based self-worth
on their abilities.
Results of a multiethnic study of 877 adolescents in Los
Angeles (Siegel, Yancey, Aneshengel, & Schuler, 1999) sug-
gest that body image and even the impact of pubertal timing
vary considerably as a function of both gender and ethnicity.
Asian American boys and girls reported similar levels of
body satisfaction whereas boys were more satis“ed than girls
for all other ethnic groups of teenagers. Overall, African
American girls had the most positive body image and, in
sharp contrast to the other ethnic groups, were not dissatis“ed
with their bodies if they perceived themselves as being early
maturers. As with African American boys, African American
girls were least satis“ed with their bodies if they perceived
themselves as late developers. Given that boys• body image
improves with age, that Asian American girls appear less
concerned about physical appearance than girls in other eth-
nic groups, and that African American girls have a relatively
positive body image, the authors conclude that the most
problematic teenagers are White and Hispanic girls, both of
whom evidence dissatisfaction with their body image, which
becomes increasingly negative with age.
Special Conditions
Gynecomastiais a benign increase in male breast tissue asso-
ciated with puberty, not the fatty tissue often seen with obese
patients. It is found in about 20% of 10.5-year old boys, with
a peak prevalence of 65% at age 14 (mean age of onset is
13.2). About 4% of boys will have severe gynecomastia, with
very evident, protruding breasts, that persists into adulthood.
Gynecomastia is thought to result from an imbalance between
circulating estrogens and androgens, thus representing a
normal concomitant of hormonal change during puberty. The
condition usually resolves in 12 to 18 months but can last for
more than two years.
Given that more than half of adolescent boys experience
this condition, and at a developmental stage when concerns
about their bodies and relationships with their peers are at a
lifetime peak, it is remarkable that so little data are available
regarding psychological impact and treatment. Clinical
experience indicates that many young adolescent boys are
seriously concerned about their breast development and its
implications for their sexual development and identity, often
prompting them to avoid sports or other activities that require
them to remove their shirts. At a minimum, explanation and
reassurance is required. Medical intervention is limited,
largely due to concern about side effects, but Tamoxifen (es-
pecially) and Testolactone may provide relief for adolescents
with signi“cant psychological sequelae. Sur gery is another
useful option for boys with moderate to severe gynecomastia
or in cases where the condition has not resolved after an
extended period of time. Surgery may not be an option, how-
ever, for many boys because it is considered to be cosmetic
surgery and not generally covered by health insurance.
Abnormal maturational delayis de“ned statistically as
those 5% of teenagers who fall at least two standard devia-
tions above the mean onset of puberty. Physical examination
and laboratory tests are employed to screen for a variety of
disorders that may cause delay: hormonal de“ciencies (in-
cluding growth hormone), chromosomal abnormalities, and
chronic illness (e.g., cystic “brosis, sickle cell anemia, heart
disease, or in”ammatory bowel disease), which may be undi-
agnosed. In some cases, medical intervention can promote
catch-up growth and sexual development but the effects are
irreversible in most cases. However, 90% to 95% of delayed
puberty represents constitutional delay rather than an under-
lying disease or abnormality.
Neinstein and Kaufman (1996) report (anecdotally) that it
is, not surprisingly, most often male adolescents who com-
plain about delayed puberty. Treatment with hormones often
can increase growth velocity without excessive bone age ad-
vancement, but potential side effects, such as the possible
attenuation of mature height, must be considered. It is not
only psychological sequelae that are of concern. Adult men
with a history of constitutionally delayed puberty have de-
creased radial and spinal bone mineral density, suggesting
that the timing of sexual maturation may determine peak
bone mineral density (Finkelstein, Neer, & Biller, 1992).
Delayed menstruation(primary amenorrhea) is de“ned as
the absence of spontaneous uterine bleeding and secondary
sex characteristics by age 14 to 15, or by 16 to 16.5 regardless
of the presence of secondary sex characteristics. Such delay