text:
AMANDA DUNN is the politics and society editor for _The Conversation._ Prior to that she was a reporter and editor with _The Age_ for 16 years.
**THE NEW
PUBERTY**

**AMANDA DUNN**

MELBOURNE UNIVERSITY PRESS

An imprint of Melbourne University Publishing Limited

Level 1, 715 Swanston Street, Carlton, Victoria 3053, Australia

mup-info@unimelb.edu.au

www.mup.com.au

First published 2017

Text © Amanda Dunn, 2017

Design and typography © Melbourne University Publishing Limited, 2017

This book is copyright. Apart from any use permitted under the _Copyright Act 1968_ and subsequent amendments, no part may be reproduced, stored in a retrieval system or transmitted by any means or process whatsoever without the prior written permission of the publishers.

Every attempt has been made to locate the copyright holders for material quoted in this book. Any person or organisation that may have been overlooked or misattributed may contact the publisher.

Cover design by Design by Committee

Typeset by Sonya Murphy, TypeSkill

Printed in Australia by McPherson's Printing Group

National Library of Australia Cataloguing-in-Publication entry

Dunn, Amanda, author.

The new puberty/Amanda Dunn.

9780522870763 (paperback)

9780522870770 (ebook)

Includes index.

Adolescence—Social aspects.

Puberty—Social aspects.

Adolescent psychology.
_For Molly_
**Contents**

**Part I: What's Happening to Our Kids?**

 1 Of Boobs and Pubes: Why Kids Seem to Be Going through Puberty Earlier than Ever

 2 There's Hair Down There! The Purpose of Puberty

 3 Choppy Waters Ahead: The New Adolescent Sets Sail

 4 From Shyness to Hysteria: Why We Need to Get Better at Talking about Sexual Development

 5 Hopscotch and Hormones: Development in the Middle Primary Years

**Part II: Girls and Puberty**

 6 What's Happening to Me?

 7 Period Drama: Our Struggle to Deal with the Bleeding Obvious

 8 Pubertal Problems for Girls

 9 'Don't You Look Pretty?': Body Image, Sexualisation and Mental Health in Pubertal Girls

**Part III: Boys and Puberty**

10 What's Happening to Me?

11 Pubertal Problems for Boys

12 Grunt Work: Boys' Social and Emotional Development into Men

**Part IV: Sexuality Education: the Urgent Need for Reform**

13 Beyond the Birds and the Bees

14 Mandatory Sexuality Education: the Right to Know

15 Let's Make It Happen (and Make It Good)

Acknowledgements

Notes

Index
I

What's Happening to Our Kids?
Chapter 1

**Of Boobs and Pubes**

Why Kids Seem to Be Going through Puberty Earlier than Ever

WHAT IS YOUR most vivid memory of puberty? Is it stuffing tissues in your bra to make your boobs look bigger? Is it a period that arrived unexpectedly and shocked or embarrassed you? Is it looking sideways at the other boys in the class who were taller, bigger and hairier than you and wondering what was wrong with you? Is it people making fun of your growth spurt, or an unwanted erection?Your flat chest? Or do you remember constant anxiety and insecurity about who you were, what you were good at, whether people liked you, what made you special?

I have a vivid memory of realising I had hit puberty—as it turned out, it was when puberty hit me. I was in Year 6, so about 11 years old, standing in a crowded tram heading into Melbourne. It was 1984 and I fancy that, in keeping with the times, I may have been sporting a side ponytail (and it may have been permed, but that's a whole other book). Without warning, the man standing in front of me turned around and accidentally elbowed me in the chest. The pain was terrible, like something hard yet tender and a little bit alien had taken residence in my body, shocking me so much I almost burst into tears. Well, I thought, when I'd regained my composure, this is new. I had no idea what breast buds were, but they had introduced themselves to me in no uncertain terms.

As it turned out, my puberty was one of those protracted ones—everything seemed to happen later for me than most of my friends. And when puberty finally did knock on my door, it was not particularly welcome. In the skewed world of ballet in which I was absorbed, breasts or hips or a womanly shape of any kind were generally frowned upon, as was the solid physique I was sporting, which I would continue to sport into adulthood. My development was, to me, something to be embarrassed about rather than celebrated and embraced.

Whatever your own memory of making the often-awkward transition from child to adult, chances are it is not a particularly happy one either. Why should this be so? Puberty is as old as human life and a vital, natural function—without it, life would come to an abrupt end. So why should it be so miserable for so many of us?

The primary answer to that question is that we're still as awkward as hell when it comes to talking about puberty—to our friends, our parents and particularly to our kids. The education system struggles too. Sexuality education happens on an ad-hoc basis, and flares into controversy more often than is necessary. Governments tread warily, and so do schools. There is a strange cultural reticence behind this—as though talking about those physical changes, and the burgeoning sexuality and reproductive capability they represent, is something shameful and a bit dirty. It's high time we acknowledged how damaging that is and changed our approach, especially in light of what I began to notice over a decade ago.

In the early 2000s, I was a schools reporter—later health reporter—for Melbourne's _Age_ newspaper. One day I found myself at a primary school for a story and, watching the students mill around at lunchtime, something struck me: the senior girls, the Year 5s and 6s, were so _big._ They were tall, they had obvious breasts—they looked like grown women wearing little girls' faces. This seemed to me to be a radical shift from when I had been in Grade 6 two decades earlier. Again and again when I went into primary schools, I was struck by how physically developed the kids seemed.

I was not the only one who noticed this change. Media stories started to appear reporting that puberty was happening earlier, and how worrying this was, particularly for the parents of girls. But the focus seemed to be mostly on when girls had their first period, and the evidence was patchy. Some reports included a medical expert saying, somewhat confusingly, that the age of menarche (pronounced 'men- _arkee_ ')—a girl's first period—had dropped significantly in the past century but had recently plateaued (which is in fact the case, but like most matters of health and human development, it's complicated).

At the same time, there were constant stories about the sexualisation of young girls; the aggressive marketing to them of 'adult' clothing, make-up and ideas; the sense that they were being pushed out of childhood too soon, for nefarious money-making reasons—with huge psychological and social implications. For boys and girls more generally, there was also the encroachment of social media and the proliferation of all kinds of other entertainment that meant they were being exposed to adult ideas and issues earlier than ever before, that the barriers that had once protected childish innocence were being broken down.

In early 2015, when I returned to _The Age_ from maternity leave, I wrote a story based on the research done by Professor George Patton, head of adolescent health research at Melbourne's Royal Children's Hospital and an international expert on puberty. Having taken a keen interest in adolescent health as a roundsperson, I had worked many times with Patton and his colleague, Professor Susan Sawyer, on a range of issues to do with young people's physical and emotional development.

Patton is overseeing a project called the Childhood to Adolescence Transition Study (CATS). He and his team are investigating exactly when puberty begins, how it unfolds, why children reach it at varying ages and stages, and the impact it has on all facets of children's lives. The researchers are particularly interested in an earlier, and largely unknown, form of puberty known as adrenarche, which happens to children at around eight years of age. They have found that while there are no physical signs of development at this age (which is about Year 3), there is a distinct hormonal shift that affects children's emotional wellbeing and their relationships. Boys seem to be particularly affected—a neat reversal of puberty proper, during which, in general, girls are more affected. This means that the entire pubertal process is longer and begins earlier than we thought, and that's even before factoring in that physical development is starting earlier.

Why does this matter? Well, going through puberty earlier is a big deal because it marks, at least from a physical point of view, the end of childhood and the start of adolescence, and the beginning of sexual and reproductive maturity. And because of that, no matter how smooth a kid's puberty might be, it's hard to escape feeling just a little melancholy that it is encroaching further into childhood, a time we like to think of as unselfconscious and free of adult concerns. For girls in particular, physical puberty, or gonadarche, immediately sexualises the body, in a way that is understandably concerning when it strikes young children. It has implications for their physical, social and emotional wellbeing. Much about these complex issues, and the point at which they intersect with puberty, remains a mystery, even to adolescent health experts.

While researching Patton's work, and afterwards, I was struck by the strange ideas that people had absorbed, seemingly by osmosis, from the media or friends or pop culture. Was it true that you had to weigh 50 kilograms for puberty to start, asked one friend. Another was sure that the later you reached puberty, the earlier you went through menopause. Most thought of a girl's first period as 'puberty', without realising that puberty actually starts much earlier than this, and that menstruation is a late milestone of pubertal change in girls.

I realised how little we collectively knew about how our bodies work, particularly about how reproduction happened. My own poor knowledge in this area had slapped me in the face (figuratively, of course) when I had undergone IVF (in-vitro fertilisation) treatment to have my daughter, and I found myself, for the first time, really understanding the menstrual cycle and the role that hormones play in various aspects of it. I was surprised and a little embarrassed that I hadn't known all of this. Why hadn't I been taught it at school? What had caused these holes in my education? What was this strange timidity that gripped me and others when it came to talking about our bodies and the changes we all go through?

And what of menstruation, the event that has attracted perhaps the most research attention of all? It's hard also to escape the idea that we still haven't quite come to terms with the fact that women bleed once a month, which evokes a kind of mixture of fascination and disgust that ensures any information about menstruation will garner attention. An example of our ongoing squeamishness is that one of the most complained-about categories of advertising on television is for pads or tampons, most of the concerns along the lines that it is a 'private' matter, not one that needs to be shouted about (or celebrated, god forbid) on prime-time television.

All of this continued to swirl around the back of my mind. Pregnancy taught me still more, and then later, holding my baby daughter in my arms, I wondered how all of this would be for her: How would her childhood be different from mine? What would be the biggest influences on her development through childhood? How could I strike a balance between protecting her but not making her fearful, building a confident and assertive young woman who knew how to look after herself and others? And what about boys, what was happening with them? Were they going through puberty earlier, and if so, why? How would that shape the men they became?

These questions need to be answered in the context of contemporary life, with all its complications. We are in the middle of a dramatic shift in the way we live, work and communicate. It is fundamentally a technological revolution, but it affects almost every facet of our lives. In many ways, it is brilliant and fun and efficient—how many of us can imagine life without mobile phones anymore? But it also means that information is more accessible than ever before, which means children are seeing and hearing things they are not old enough to understand or process. In a subtle way—and sometimes with a complete lack of subtlety—they are having adult pressures put on them about how they look, what they do and what they know.

So at one end of the scale, adolescence is being thrust on children, in all sorts of ways, earlier than ever. But at the other end of the scale, it is being stretched into our 20s—the journey from child to adult is a long one these days. Adolescence itself is a relatively new phenomenon, unheard of until after World War II, and born of changes to health, life expectancy and gender roles that have extended and sanctified the period between childhood and adulthood.

Where once—not that long ago—people finished school, got a job, married and had children in relatively quick succession, today's economic and social environment is vastly different. The median age for first marriage continues to rise—in 1986, it was 23.5 years for women and 25.6 for men, but by 2015 it had leapt to 28.5 and 30.1 years, respectively. And many people decide not to marry at all, which is no impediment to having children: in 2015, 34 per cent of babies were born to parents who were not married. That is a massive population-level shift in less than 30 years.

The change in the age at which women become mothers is just as stark. Australian Institute of Family Studies figures show that in 1971, the average age at which a woman had her first child was 23. By 2014, that had jumped to 29, and that seems likely to continue to rise. The proportion of women having their first baby at 40 or older—unheard of a generation ago—is growing fast, while the number of new mothers aged under 20 is dropping significantly. Changes to IVF laws means more women are choosing to be single mothers, while gay couples now have access to fertility treatment or can enter into agreements with others in order to become parents. Some women choose not to become mothers at all. While many people remain deeply uncomfortable with these developments, including some of our political leaders, the idea of the family—and as a consequence, of parenting—is changing, and fast.

On the economic front, a protracted adolescence is being imposed on young people. You don't have to click through many media sites to find a story about young people being 'shut out' of the housing market, particularly in the major cities, as house prices continue to gallop and supply struggles to keep up with demand. This means it is now far more common for young adults to still be living at home with their parents well into their 20s or even their 30s in a bid to save up enough money for a deposit. Often, they are shut out of the rental market too.

The deregulation of higher education means that more young people have degrees, but that in turn means that holding a degree is less remarkable than it once was, and they often need to go on to further study to differentiate themselves in a competitive job market. Youth unemployment remains far higher than the overall jobless rate, and study is often a better option than working, at least in the short term. But study is costly, both at the time and for many years to come as young people pay off their accumulated debt.

Fortunately, baby boomers and gen Xers seem to have relatively good relationships with their children, which allows the accommodation of this kind of cohabitation and financial help long after the kids have turned 18. This also reflects another significant shift in the way we live now, which is the way we parent. In the media, on the internet and in life in general, often-judgmental and bossy attention is paid to parenting, with many parents constantly anxious about 'getting it right'. This is, of course, a double-edged sword: on the one hand, children are listened to, invested in and indulged more than ever; on the other hand, children are pandered to, spoilt and sometimes overprotected from life's challenging but formative experiences.

All of which brings us back to puberty, because the changes we are seeing in pre-pubertal and pubertal children can only be understood within a broader sociocultural context. For young people trying to figure out who they are, puberty can be a confusing and challenging time. But it's also a great opportunity for adults to help shape young people as they make their way into our ranks, and set them up for happy, healthy and productive lives. So if puberty is changing and happening earlier, we need to concern ourselves with it.

A friend, reflecting on how developed his 12-year-old daughter and her friends suddenly seemed—breasts, acne, the works—summed it up bluntly, but well: 'Something's going on'. What is that, exactly?

One of the best snapshots we have of Australian children and pubertal development comes from the Longitudinal Study of Australian Children (LSAC), a large, long-term study run by a federal government body, the Australian Institute of Family Studies. In an analysis published in 2016, LSAC researchers looked at how more than 12 400 Australian children aged 8–13 were developing, specifically the pubertal changes they were undergoing. The children's parents were regularly asked to fill out questionnaires covering behaviour issues, problems at school, and signs of physical development such as pubic hair or breast buds. One of the most striking findings—although it is important to note that these data are limited because they are parent-reported, rather than scientifically measured—was that almost one in four girls aged 8–9 had started to develop breasts (this included those for whom it had 'definitely started' and those for whom it had 'barely started'). This is important because, in the debate on early puberty, breasts are where the developmental action is, so to speak.

In fact, by that age, 40 per cent of girls and 21 per cent of boys were showing some sign of the onset of puberty, such as breast buds, skin changes or pubic hair (it is well established that boys generally go through puberty a year later than girls). By age 12–13, almost all girls and about 95 per cent of boys were showing signs of puberty. Interestingly, the age of menarche seemed to align with the figure quoted by medical experts: that on average it happens between the ages of 11 and 13–12.5 is the most oft-quoted median age. Although the question was not asked about girls aged 8–9, the data show that by age 10–11, 5.7 per cent of girls had had their first period, and by age 12–13, 57 per cent were menstruating.

Unfortunately, there is no comparable data from, say, 30 years ago to show how this might have changed, certainly not from Australia. But these figures are nonetheless striking. How many of us over the age of about 30 remember girls having breasts in Year 3? I doubt I even knew what they were at that age, even though I was pretty keen on holding hands with my special friend Jason in the back row of the classroom.

I spoke to teachers, parents, doctors and psychologists about all of this. All were worried and perplexed by the changes they were seeing. Prominent child and adolescent psychologist Michael Carr-Gregg told me that in 30 years of clinical practice, he'd never seen anything like it. He had no doubt that there was a group of kids going through puberty earlier and it was raising a host of issues: shifting relationships, effect on schoolwork, and, importantly, a disparity between the children's physical development and their psychosocial development. It is this disparity that is the main concern—a body that has become an adult's and is perhaps mistakenly viewed as such, attached to a mind that is still a child's.

Adolescence has been a mysteriously neglected area of research, which to me fits in with that overarching idea that it's just something we have to grit our teeth about and 'get through', hopefully emerging relatively unscathed at the other end. Carr-Gregg said that when he decided to specialise in adolescent psychology in the 1980s, his colleagues reacted with horror, telling him he was wasting his time on a group that attracted little research attention. Since then, interest in adolescent health—relating to a specific time of life, with distinctive physiological, psychological and emotional challenges—seems to have gathered pace. But it is still catching up to the understanding we have of other stages of human development.

Fear of 'The Teenager' has spread its tentacles deep in our culture. A person's puberty, in particular, can make others assume the brace position, even if—or perhaps especially if—they remember it as a challenging time themselves. The vibe is that eye-rolling, deep-sighing, get-ready-for-the-slamming-doors-and-monosyllabic-grunting approach that speaks to adults' intolerance of young people. There are the 'Oh, you've got teenagers' comments of which so many of us are guilty, reinforcing a negative adolescent stereotype. We tend to treat teenagers with suspicion and fear, and in doing so we miss out on a great opportunity to play a more meaningful role in shaping their lives.

Governments have invested a great deal of money and other resources in the early years—the vital 0–5 years of pre-school development—matching the understanding that so much of what happens to people later in their lives is set in train when they are very young. And it's entirely right that they do so. But along the way, a little bit of laziness slipped in. Even among the experts there was a feeling that the middle primary years—that seemingly easy period between early childhood and puberty—was a 'latent' phase in which nothing much happened. Increasingly, that is being shown to be untrue. The CATS work shows that a big hormonal shift is taking place, and the LSAC data support the idea that puberty proper is encroaching on those primary school years. This means that we need to overcome our reluctance to talk about young children and their development, and take a proactive approach to finding out what is going on, and changing to match it. It is a sobering statistic that 75 per cent of adult mental health problems have their onset by the age of 24, and 50 per cent have shown themselves by age 14. Something is going awry in those exciting but delicate adolescent years.

The big question is: Why are children experiencing puberty earlier? Again, we come back to that frustrating but nonetheless accurate answer: the reasons are complex and not entirely clear. It is important to note that it is by no means a settled matter within the medical community. There's not a lot of great data on pubertal development, and while many of the doctors I spoke to gave an excellent insight into what they are experiencing and treating in their clinical practice, what is happening at the population level is harder to pin down.

One of the points of contestation is whether the earlier signs of puberty that doctors are seeing are part of or separate from puberty. For example, Associate Professor Michelle Jack, a Sydney-based paediatric endocrinologist (hormone specialist), told me that she is certainly seeing more cases of young girls with premature pubic hair or thelarche (breast development). However, she says this is not early puberty as such, but rather isolated cases of development. Most of those children, Jack says, do not then go through the rest of puberty unusually early. But they do suffer the emotional effects of early puberty, and it can cause the children and their families considerable distress. Similarly, Phil Bergman, head of paediatric endocrinology and diabetes at Monash Health, which services the families of Melbourne's sprawling south-eastern suburbs, also says he is treating more cases of premature thelarche but sees this as separate from actual pubertal development.

Other doctors read what is happening as puberty starting earlier (as in, this is all part of puberty's protracted process). In some ways this is a semantic debate, as one doctor I spoke to noted: it's important for doctors to understand exactly what is happening on a clinical level. But in other ways, as feminist author Gertrude Stein might have said, breasts are breasts are breasts. What is clear from all of this is that, given the cultural and social context in which kids are growing up, and the way in which the internet is shaping their lives, a child's path to adulthood is changing and greeting them earlier.

Having said that, there are a few things we do know. Changes to diet in recent decades is certainly a big factor, more specifically the rise in obesity in children, although the exact nature of the relationship between body fat and earlier onset of puberty has not been established. Some experts also believe that environmental factors play a role, such as the so-called endocrine disruptors, or substances that can change the body's hormonal activity (for example, mimicking the function of oestrogen in the body). The evidence on this also is not yet clear, and the debate around it remains heated, but it is a vital part of determining what is happening to our children and the implications for their health in the long term.

A key reason menarche has dropped significantly in the past century—really since industrialisation—is one of the best possible: our overall health is better. We are better fed now (even if a little too well), and there has been a significant reduction in childhood infections, which can delay puberty. In short, taking into account the problem of obesity, earlier puberty is both a positive and negative indicator of overall health.

But we also need to think about the broader impact on a population of children when a significant cohort reaches puberty earlier: the effect it can have in recalibrating expectations and creating a kind of 'new normal'. When puberty calls on a group of kids, things will never be the same again. It changes their relationships, including those they have with their bodies, as well as their emotional engagement and awareness of other children's bodies. Unfortunately, one of the things we have been very bad at historically is talking to children about puberty—before they go through it, rather than when it is already well underway. We tend to walk them through it in secondary school, or even in upper primary school, when it is too late.

The CATS project, where pubertal changes are reported directly by the children, is instructive on this. Analysing data collected from more than 1000 children aged 11 and 12 (in Year 6), it found that by the last year of primary school, fewer than one in 10 girls had not yet started to develop breasts, and only 17 per cent of girls and 27 per cent of boys did not yet have pubic hair. In other words, Year 6 is far too late to talk to adolescents about what to expect from puberty: most of them are already deep in it. There's not much point in teaching kids about the changes they're likely to undergo at the same time as you're buying them tampons and razors. This is why it's crucial that sexuality education begins much earlier in primary school, to ensure that all children get high-quality, age-appropriate information about what is happening to them, and develop the confidence and resilience to pass through puberty as smoothly as possible.

For better or worse, we live in a highly sexualised world. The internet offers us a sensible answer to just about any question, but it also offers a whole lot of garbage, some of it corrosive and dangerous. As we cannot turn back the cultural tide, we need to conduct a counteroffensive—more and better-quality education in schools that demystifies sexuality and builds maturity and resilience in young people.

We are seeing a major shift in the development of children, particularly girls, set within a morphing cultural environment and a technological revolution that is sweeping everyone along. These changes are complex and vitally important, and we cannot afford to ignore them and hope they will go away. Hysteria is not helpful either. This is not the 'end' of childhood but the reconfiguring of it. It has huge implications for how we teach and raise our children, and offers a rare opportunity to overcome our prudishness about talking about puberty.

My friend was right. Something is happening to our kids, and it's time we talked about it.
Chapter 2

**There's Hair Down There!**

The Purpose of Puberty

PUBERTY'S HALLMARKS ARE well known: the oily, acne-prone skin; the sprouting of pubic hair; a sudden growth spurt; body odour; breasts for girls and wet dreams for boys. And the sudden high emotion, seemingly at the slightest provocation, or with none at all: it can be a bewildering time for adolescents and those who care for them.

At first glance, the purpose of puberty seems pretty obvious: it's the physical and emotional transition from childhood to adulthood. Along the way, we develop sexual maturity—the ability to reproduce and therefore ensure the survival of our species. So far, so Darwinian.

There are a few theories as to why we have pubic hair, particularly on our genitals, the most persuasive of which is that it guards against infection (and therefore should be left alone, which cuts across our current cultural obsession with ripping out every last hair on our bodies). And breasts have the dual purpose of allowing women to breastfeed the young, and providing sexual pleasure for both women and men. Oestrogen is the hormone responsible for breast development, and we all have it, even though men have less of it than women (and for the male sex hormone testosterone, the converse is true). This is why boys and girls develop nipples in the womb, and why some boys, particularly those who are overweight, can develop breasts.

Puberty occurs when the hypothalamic–pituitary–gonadal axis swings into action, a term you may like to casually drop at your next dinner party (though be prepared for the invitations to mysteriously dry up afterwards). Here's what happens. At the base of our brains is the hypothalamus, which controls the link between our hormones and our nervous system. No-one knows exactly why or how the hypothalamus swings into pubertal action when it does, but nonetheless, it sends out increased amounts of gonadotropin-releasing hormones (GnRH) in little pulses, activating the pituitary gland that sits just beneath it. The pituitary gland in turn sends out two important hormones, follicle-stimulating hormone (FSH) and luteinising hormone (LH), which stimulate the production of the sex hormones oestrogen and testosterone in the ovaries and testes, respectively.

In girls, FSH awakens the ovaries, causing them to release the eggs that enable reproduction—this does not happen immediately, however, so a girl usually remains infertile for her first few periods. LH also stimulates the production of oestrogen in the ovaries, and it is oestrogen that is primarily responsible for other pubertal development such as growth of the breasts, uterus and ovaries, along with a change in the shape of the pelvis and hips to support future childbirth.

In boys, FSH causes the enlargement of the testes that signals an early stage of puberty; LH helps the Leydig cells in the testes produce testosterone, which in turn causes further male physical development such as facial hair, pubic hair, sperm in the testes, growth of the penis and voice deepening. This is all a slow process—the hormonal shifts in children usually take place some years before any physical changes become apparent.

There's also that time when, quite suddenly, you notice that your child is bending down to hug you, or is suddenly very useful in retrieving goods from high shelves. Midway through puberty, both boys and girls undergo a significant growth spurt—at about age 12 for girls and 14 for boys. Overall, 12 is the time of the greatest average growth, a sure sign that puberty is well underway.

This whole set-up of the hypothalamic–pituitary–gonadal axis is in place—rather brilliantly—by 14 weeks' gestation. Our reproductive system is largely intact before we are even born: the body has a clever way of putting it to sleep for several years until we are developed enough to use it. There are 6–7 million eggs in a baby girl's ovaries by five to six months' gestation; by the time she is born, that has dropped to 1–2 million eggs; and by puberty only 300 000–500 000 eggs remain. During a girl's menstrual years, the number of available eggs, and their quality (in reproductive terms), gradually declines until the ovaries stop releasing eggs altogether. Much later in a woman's life, at around 51 years of age, menopause—the cessation of menstruation—takes place.

In terms of how puberty manifests itself, it should be remembered that there is a vast range of 'normal' in the chronology of the changes and the speed at which they take place. Generally, the first signs of puberty in girls are breast buds and pubic hair, and in boys it is pubic hair and body odour (actually, the first sign in boys is an increase in testicular volume, but this is largely invisible, even to the boy himself). In both sexes the skin can start to change and acne appears. Girls will go on to menstruation—typically about two years after their breasts begin to develop—while boys will have wet dreams and uninvited erections, and their voices will deepen.

One of the most widely used markers of pubertal development is the Tanner scale, first published by British paediatrician James Tanner in 1969 (girls) and 1970 (boys). In it, Tanner identifies five key stages of development in male genitals, female breasts, and pubic hair in both sexes. Medical experts still cite the research today; it remains a key diagnostic tool in clinical evaluation. In developed countries like Australia, the physical changes of puberty commence in girls when they are on average 10–11 years of age; in boys, it happens about a year later, at 11–12 years. Again, there is a big variation in the time it takes to pass through each stage, but generally it takes about 4–5 years for puberty to be completed. Puberty tends to take longer for children who enter it earlier; conversely, late developers are more likely to pass through it quickly.

One of the major difficulties in trying to figure out what is happening with puberty is the paucity of reliable and comparable data, a frustration for medical researchers (and journalists). Puberty is also tricky to measure, creeping up as it does on a young person—researchers often have to rely on a child's self-report or, less accurately, a parental report to know what is going on.

There is also vastly more information available on puberty for girls than boys, primarily because the onset of menstruation is the most obvious marker of pubertal development. And unlike the presence of pubic hair, there's no 'maybe' or 'a little bit' about it: girls either have their period or they do not, and most remember when it started. This explains why much of the recent anxiety around the drop in the onset of the age of puberty has been around girls, mostly because pubertal development is easier to measure with accuracy (and even observe casually) in girls. There is a sense, too, that puberty proper (as opposed to adrenarche) affects girls more particularly than it does boys. As puberty is the gateway to fertility, and women's fecundity has a much narrower time frame than men's, this may be another reason it has attracted more attention.

While precocious puberty also seems to mostly affect girls—conversely, delayed puberty (starting later than 12 for girls and 14 for boys) more commonly afflicts boys—there is some evidence that boys' bodies might be maturing earlier too. A US study in 2012 found that boys were developing pubic hair and greater testicular volume six months to two years earlier than had been previously observed in the 1969 studies used as the benchmark for pubertal development.

While other studies have drawn the same conclusion, the degree to which boys are following girls into developing at a younger age is nonetheless still contested among researchers. But even if boys are not as affected by these changes as girls, there are still significant implications for them. That's because this is not just about physical development but social and emotional development, too—the whole package of moving from childhood to adolescence.

There are many other possible or probable factors in the timing of puberty that make logical sense: genetics, ethnicity, childhood trauma and family set-up among them. These operate more at the level of the individual rather than the population. In assessing each of these, it is important once again to draw back the lens and examine what it is like to be an Australian adolescent in the 21st century, and how that has changed from even a generation or two ago.
Chapter 3

**Choppy Waters Ahead**

The New Adolescent Sets Sail

WHAT IS AN adolescent? You may think you'd know one if you met one in the street, but adolescence is not the same as puberty, nor is it the same as the teenage years, though the terms have become conflated and are often used interchangeably. The World Health Organization says adolescence is the period between 10 and 19 years, and these days it would be accepted that puberty starts somewhere between eight and 13 years, so while the two overlap, they are not the same. Adolescence is, in fact, the slow transition from child to adult, while puberty is the gaining of sexual maturity—in other words, puberty is a significant part of adolescence. At the moment, we have the largest generation of 10–24-year-olds in human history, yet another reason, if we needed one, to really understand how puberty is changing.

What we do know is that the onset of puberty has fluctuated quite dramatically over the centuries. The life history school of thought, which looks at puberty from an evolutionary perspective, offers up a fascinating explanation for why we have developed the way we have. To begin with, researchers estimate that, in Palaeolithic times, females would have begun their periods around the age of 7–13, not vastly different from what it is today, and reached fertility between 11 and 13. (Of course, life expectancy was much shorter then, so everything is contracted relative to that.) But with settlement came undernutrition and childhood disease, delaying menarche further. As population density increased and hygiene deteriorated, menarche was again delayed, and by medieval times, periods started at an average of 16.5 years.

Industrialisation from the late 18th century was the event that saw the age of menarche begin to decline, which is widely attributed to improved nutrition and, gradually, a reduction in childhood infection. Since then, the age at which a girl begins her period has dropped by a good four years to about 12.5. At the population level, that is a very significant shift, especially when you compare the emotional and social differences between the average 16-year-old and the average 12-year-old.

Over that time, our physicality has changed dramatically. In Western countries in particular, we are fatter than ever before, finding ourselves in the middle of an obesity epidemic. In this respect, Australians are among the worst-afflicted people in the world, falling prey to a sedentary lifestyle and an abundance of cheap, easily accessible high-fat and high-sugar food. We've expanded our personal empires accordingly, with men whacking on an average of 3.6 kilograms between 1995 and 2011–12, while women have gained an average of 4 kilograms over the same period. We are large people.

We're getting taller too. Every generation is about 3–4 centimetres taller than the one before it, and we are almost 15 centimetres taller than we were 150 years ago. The average Australian man aged 18–24 is 177.8 centimetres, while the average Australian woman of the same age is 163.8 centimetres.

Just as adults are getting bigger in every direction, many children are also becoming enlarged—although interestingly, the once-alarming rise in childhood obesity does appear to have plateaued in recent years, perhaps due to a number of high-profile public health campaigns and school-based initiatives. Nonetheless, it's still a major problem: one in four Australian children aged 2–17 is either overweight (18 per cent) or obese (7 per cent), with little difference between the genders.

But that's just the body. What about the brain? We now know that adolescence is also a time of major neurological development that continues well into a person's 20s, perhaps even up until age 30. Functional magnetic resonance imaging (fMRI) studies have shown that the adolescent brain continues to develop and reorganise itself in a way that is reminiscent of the toddler years, and so should be seen as just as significant. And researchers are only just beginning to understand the effect that hormones, particularly sex hormones, have on the brain (previously, it was thought that they were only responsible for reproduction). Scientists are looking at how these hormones interact with brain function and structure, potentially highlighting some important differences between the sexes.

What does this mean in terms of puberty? Firstly, hormones, which are so often blamed for shifts in adolescent behaviour, may not be the sole culprit. It may be that an immature brain is still developing—and that hormones and brains intersect in a complex manner. Secondly, and more importantly, if puberty is now happening earlier, it raises the issue of the disparity between young people's physical development and their neurological and psychosocial development. Are they ready to handle the changes in their bodies, and the subsequent changes to their lives?

None of this can be properly understood outside of the context of how we live now. At a cultural level, adolescence is being stretched at either end, which to me conjures an image of Doctor Dolittle creator Hugh Lofting's fanciful pushmi-pullyu, its two heads moving in opposite directions. At one end, there's the protracted adolescence we discussed in Chapter 1. At the other end, teachers are worrying a great deal about children being exposed to adult ideas and images much earlier than they once were, and then copying 'adult' behaviour in the playground. The technological revolution, for example, means that kids have access to all kinds of television programs, and parents often pay scant attention to censorship ratings. Additionally, social media and YouTube can very quickly lead kids away from something age-appropriate they might be watching into something far darker and more adult.

In terms of health, it's important to know the difference between 'earlier puberty' and what's known as 'precocious puberty'. Generally, puberty happens some time between the ages of eight and 13 for girls, and nine and 14 for boys, but boys develop about a year later than girls, and it is quite normal for girls and boys to be at the extreme end of these scales. This is different from precocious puberty, which is a clinical condition that, if diagnosed, warrants further examination. This is when the whole box and dice of puberty happens earlier, not just particular aspects of it; for example, breast development or pubic hair (though they also warrant medical examination if they occur very early). Precocious puberty is more common in girls than boys (conversely, delayed puberty—when there is no sign of physical development by 12 in girls or 14 in boys—is more common in boys than girls). It is usually investigated if development happens before the age of eight in girls or nine in boys, as there are some rare medical conditions that can cause it.

Of greater concern, though, is the impact precocious puberty might have on bone development, because the growth spurt and hormonal change are out of sync—if left untreated, children are likely to end up shorter than they otherwise would have been. So clinicians will sometimes intervene to block puberty, slowing down development and ensuring that the child grows into adulthood as healthily as possible.

And of course, there is the emotional and psychological impact of going through puberty when you are still a child—those days that are meant to be relatively tranquil and easy between toddlerhood and adolescence—and especially if you are considerably taller and noticeably different from your classmates. This can cause children significant distress, as well as changing the way other people deal with them and the expectations people have of them. So if you think your child is showing signs of precocious puberty, it is important to have her or him checked out by a doctor (I talk more about precocious puberty in Chapter 8).

There are other health factors that can play a role in the timing of normal puberty. Children with chronic disease, such as cystic fibrosis (CF), have tended to go through puberty later, though with better treatment of CF, for example, this has normalised. Children with conditions that affect the brain can reach puberty earlier, which is why they need to be examined if they start to develop at a very young age. And as with most health issues, genes play a role too: if your mum got her period early, it's likely that you will too. One of the really interesting findings from the LSAC confirms this, but it also suggests a link between the time at which the father reached puberty and when his kids will mature. This means that the pubertal history of both parents may affect when a young person will develop. While a father's history is perhaps not as significant as a mother's influence on when her daughter will have her first period, it further stresses the role that genes play in young people's development.

Ethnicity is another significant factor. Studies from the United States show that black Americans reach puberty considerably earlier than white Americans. We also know that Asian girls have typically reached menarche a little later. In Australia, however, there is no comparable data on ethnicity and menarche. For example, hard to believe though this is, there are no data looking at the age at which Indigenous Australian girls reach menarche compared with non-Indigenous girls. Again, this speaks to how little we know about how young people develop in this country, and the paucity of good research. We can only hope that this will be rectified in the near future.

It is well established that children from developing countries who are adopted by people in developed countries tend to go through puberty earlier than they otherwise might have, which from an evolutionary perspective is explained as adaptive behaviour (and given what we know about the role of nutrition in hastening puberty, one would have to think that a change in diet might be a significant factor).

Another factor that has often been linked to early puberty has been family set-up, particularly the presence of a non-biological male in the house, or more particularly, the absence of a girl's father. In 2010, researchers from the University of California at Berkeley found that girls who lived without their biological fathers were more likely to go through puberty earlier. This is particularly intriguing given that they took account of other factors that may have influenced the timing, such as weight and ethnicity. In higher-income families, girls living without their fathers had earlier breast development; for higher-income African-American girls, there was also the early appearance of pubic hair.

These are difficult findings to explain (and the researchers do not explain them), but those who view puberty from an evolutionary viewpoint might suggest that household instability might be instinctively perceived as a threat to survival, and so the body becomes reproductively ready earlier than it otherwise might. On the other hand—and this is just one of the ways in which research around the onset of puberty becomes tricky—the data from the LSAC confounds this finding. Bearing in mind it is a significant sample of children—well over 12 000—the researchers found that there was a link between the father's presence in the house and the timing of the child's puberty. But when they controlled the data for other factors that they know influence pubertal timing, such as weight or any chronic health conditions, they found that the absence of the father was no longer statistically significant for either boys or girls.

Instability is relevant too in well-accepted research showing that young women who grow up in high-stress families are more likely to go through puberty early, and also have their own children early. In an Australian study of 100 pregnant women led by Emeritus Professor James Chisholm and Professor Julie Quinlivan, researchers found that girls who experience high psychosocial stress—anxiety, fear, grief—seemed to reach menarche earlier and have their first baby earlier. What researchers are pointing to here, again, is something primal, Darwinian and possibly a little uncomfortable: the body's ability to adapt itself when it feels under threat, to ensure the survival of the species.

There is one further factor that may be responsible for children entering puberty earlier, though the research is by no means clear on this: environmental toxins, especially those that mimic the effects of oestrogen or that can block hormones like testosterone. A 2008 article published in the medical journal _Pediatrics,_ based on a review of evidence from the United States on the timing of puberty and environmental factors by an expert panel, concluded that breast development and menstruation happened earlier for girls in 1994 than they had in 1940. This they attributed to a combination of increased body fat and exposure to the so-called endocrine disruptors introduced in Chapter 1, those that mimic the effects of hormones such as oestrogen. The panel also said that the data on boys were inconclusive.

In her excellent book _Breasts: A Natural and Unnatural History,_ the American science journalist Florence Williams examines in detail why breasts are appearing earlier, and growing bigger, than ever. She looks at the evidence against some key environmental chemicals that have been implicated in early breast development, such as Bisphenol A (BPA), an artificial oestrogen developed in the 1930s to prevent women having miscarriages. After proving unsuccessful at that, it was later adapted to the production of polycarbonate plastics, the sort of things in ample supply in our daily lives (you may have noted that many products, such as water bottles and plates or cups for children, now advertise that they are BPA-free).

Williams details the work of Ohio scientist Patricia Hunt, who discovered quite by accident that BPA has a profound and deleterious effect on the lab mice she works with, causing abnormal behaviour or cells that lasts for three generations of mice. Williams points out that Hunt's studies are controversial because those results have not been found elsewhere. But Hunt argues that timing is crucial: that there is a specific window of opportunity for these toxins to harm the mice and affect their development. This is important because the timing of exposure to certain chemicals may also be relevant in how they affect humans.

Williams goes on to point out that mammary glands are often overlooked in research, but that they are particularly sensitive to hormonal change:

Our breasts, for better or worse, have more varied and more sensitive hormone receptors than other organs. If anything, their receptors veer towards oversensitivity. They need to sense the environment to store fat and grow at the optimal time and feed an infant in an uncertain world. What might have been handy once upon a time now looks increasingly like a liability.

This earlier and earlier encroachment of puberty on childhood is worrisome, Williams writes, because little girls are not able to cope with the changes that are happening to them: 'It's hard enough to stand your ground as a pre-teen. But an eight-year-old is pretty much incapable of it'.

The evidence that children are _starting_ puberty earlier—primarily, that they are developing breasts at a younger age—is now well established. Often quoted in this debate is the Copenhagen Puberty Study, published in 2009. Researchers followed more than 2000 young women aged 5–20 over a 15-year period, beginning in 1991. They found that the 2006 group started to develop breasts significantly earlier than the 1991 group (9.9 years compared to 10.9 years). There was also a slight drop in the age of pubic hair development and menarche, but nowhere near as significant as that relating to the onset of breasts. This in turn means that the length of puberty is increasing, with the start brought forward and the end remaining much the same.

What is even more interesting is that this difference in breast development remained even after the researchers allowed for the girls' body mass index—that is, even after they discounted obesity as a reason. The results suggested that, where once the timing of a girl developing breasts and the onset of her first period seemed closely related, now there are likely to be other environmental factors that might be affecting one far more than the other.

This issue was picked up again in a 2012 US study, in which another expert panel examined data collected over several decades on the timing of puberty in an effort to understand why girls were developing breasts earlier. They were particularly interested in the role that the rise in obesity and greater exposure to chemicals that interfere with hormones might play. Again, they noted there had been a slight shift in the onset of menstruation, but only by a couple of months. The researchers also noted that while the evidence that girls were starting puberty earlier was strong, the evidence on boys was not—in other words, as the politicians might say, they ruled it neither in nor out.

In their discussion, the researchers make two interesting observations: that our genes evolved at a time when food was much more scarce, and that there is limited opportunity for our genetic make-up to change over time. So our ancient genes are trying to cope with a modern environment in which we take in large quantities of high-calorie food and live a far more sedentary lifestyle than we once did. They also suggest that the impact of chemicals that interfere with hormones might be quite complex: that they actually heighten the risk of obesity as well as puberty—meaning they have a dual impact on the timing of puberty. This combination, the researchers suggest, may be the 'perfect storm' for contemporary young women.

In 2013, another longitudinal American study of more than 1200 girls aged 6–8 also found that breast development was starting earlier, with distinctions based on the girls' ethnicity and weight. This confirmed the relationship, in their view, between obesity and earlier puberty. In a comment piece pegged to the paper, Marcia Herman-Giddens, a leading researcher in puberty, cautioned that this trend towards earlier puberty should not be _accepted_ as the 'new normal', because of the health and psychosocial implications for children developing earlier. The conclusion of her analysis is worth quoting:

With each new study in the past 2 decades, we hope the age of 'early puberty' has bottomed out. When each 'new study' has been published, however, we find the trend toward early puberty has continued. Fortunately, we have moved beyond controversy about the data and are responding to the wake-up call.

Here in Australia, the wake-up call seems yet to take effect outside of medical research. Girls are changing. It's likely that boys are too. Teachers notice it, psychologists notice it, parents notice it. Perhaps it is excess weight that is causing puberty to shift forward, or perhaps it is environmental factors, or perhaps it is both. The causes are likely to be many and varied, reflecting the complexity of modern life. Regardless, it seems clear that young girls are developing breasts at an earlier age, changing their bodies, the way they feel, the way they see themselves and are seen by others. The science is still inconclusive about whether boys are developing earlier, and what might be causing it, but as I argued earlier, a shift forward for a noticeable number of children is in effect a shift forward for everyone, and we need to respond to it accordingly.

There have always been individual kids who have gone through puberty early: that is not a new phenomenon. All of us can remember the poor girl who stood out in primary school with her bosoms or towering height or body odour, to whom we probably weren't as kind as we might have been. But this is different. This involves a significant proportion of children, still in primary school, starting puberty earlier than in previous generations. In some ways, whether it is just breast development or pubic hair or menstruation is just the detail—interesting, of course, and important to know, but not the salient point, which is the encroachment of adult bodies and sexual maturity on younger and younger children. Add to this a sex-obsessed culture and easier access to adult ideas, and suddenly young children are catapulted into an entirely different environment from that in which their parents grew up even a generation ago.

There is little evidence that the onset of puberty will keep trending downward, but neither is there a sign of it turning around. So we need to learn about it, think about it, and work out how, if at all, we should act on it, to help young people make as smooth a transition into adulthood as possible.
Chapter 4

**From Shyness to Hysteria**

Why We Need to Get Better at Talking about Sexual Development

I WAS LUCKY ENOUGH to have had a couple of superb teachers when I was at school, people who built my confidence and imbued me with an enthusiasm for their subject area that has stayed with me ever since. So I have always had a great respect for the profession, which these days is dealing with a complex array of social problems as well as educational ones. In researching this book, I spoke with some very experienced primary school principals, as they are able to offer rich insights into what is happening with our kids, and I now want to share some of those conversations.

Mark has been teaching in primary schools for well over 40 years, and has been a principal for 25 years. For the last 17 of those, he has headed up a primary school in Melbourne's booming eastern suburbs. It's a fairly big school, with over 400 kids, and it's diverse, comprised of 41 different nationalities and with 40 per cent of kids speaking a language other than English at home. It is, as Mark says, a microcosm of modern Melbourne.

Mark remembers a Year 6 class he taught in 1978 in a working-class inner-suburban school. One of the girls in that class had hit puberty in her mid-primary years, and so she already had been developing for a few years before she entered Year 6. A comment the girl's parents made to Mark about their daughter has stayed with him all these years: 'She's got the body of a woman but the mind of a child'. It wasn't a slight on the girl. It was simply a statement of fact that a 12-year-old thinks like a child because she is one, and this particular 12-year-old was having to deal with a body that had some years ago galloped ahead of her.

Mark recalls this comment because it resonates so sharply with what he sees around him today: he has no doubt that children—particularly girls, but also boys—are reaching puberty earlier, something he puts down largely to changes in weight and nutrition. It also neatly sums up one of the key reasons why early puberty is potentially problematic, and that is the widening gap between children's physical development and their social and emotional development. Coming into sexual maturity changes the way a body looks, and is looked at. It changes relationships and, particularly in its early stages, differentiates classmates from each other.

The physiological impacts of reaching puberty earlier can be significant. Girls who do so are at higher risk of having breast cancer later in life, probably because of the increased levels of oestrogen the body produces, to which breast cancers are susceptible; that is, the more menstrual cycles you have in your life, the more oestrogen you have coursing through your body during that time. There is also an association between early puberty and increased mental health problems in adolescence, as well as an increased risk of heart disease later in life. In addition, normal puberty is important for bone growth and development in both boys and girls, which in turn is important in staving off osteoporosis later in life. Earlier puberty can interfere with this because of the timing of normal bone growth.

The potential emotional and psychological hurdles that early puberty presents are just as, if not more, significant, in that these are much harder to pin down and counteract. Again, the LSAC data shows that children who start puberty earlier (by eight or nine years of age) showed poorer emotional and social adjustment than their peers. Early puberty was also linked to behavioural problems. The good news is that later, when almost of all the children's peers had caught up and gone through puberty as well, those differences became less significant.

There is no escaping the fact that puberty changes the role of the body and how it is seen by others. Add another slightly pernicious influence—access to adult images through various media—and the environment potentially becomes much darker. Mark says he has seen a big jump in sexualised behaviour by the kids at his school, some of which he calls 'horrendous'. Teachers hear sexualised verbal abuse thrown around in the playground at lunchtime, or see it left in comments on blogs.

Debbie, the principal of a large, ethnically diverse Melbourne school, where more than 700 children are in her charge, says the same thing. She agrees with Mark that kids mostly watch whatever they please on television or, perhaps more worryingly, on YouTube, where it doesn't take long for them to come across sexualised or other adult content— _The Walking Dead_ seems to be a favourite, a series that is R-rated because of 'high-impact violence'—which they then replicate at school. Such imagery, whether it involves violence or pornography, or both, is never far away, whether kids mean to find it or not.

Children are great mimics: it's how they learn language, facial expressions, body movements, and pretty much how to be a human being in the world from the day they are born. (I had this powerfully illustrated to me when my three-year-old announced she was bringing in our 'crap' from the car, a term I have been known to employ from time to time.) Some troubling evidence has recently come to light that large numbers of children are sexually abusing each other in Australian schools, and it's not difficult to imagine that they are simply copying behaviour they have picked up while surfing the internet or watching television. Doctors, teachers and parents worry about young people's access to pornography, and the kind of behaviour and gender relations the worst of this models and sanctifies.

Medical professionals, including psychiatrists, are also worried about an increase in sexualised behaviour at the primary school level. Professor Jayashri Kulkarni, who heads up psychiatric research at Melbourne's Alfred Hospital, told me that she has treated Year 6 girls who have been traumatised by sexualised activity they have witnessed. 'Dry humping' is apparently one going concern at primary school, the result of young children copying what they think adults are doing. The trouble is that, in their mimicry and confusion, they can frighten the hell out of other children.

Let's not forget that there is also normal sexual curiosity and exploration, and it's not necessarily helpful to thunder down on kids when they copy behaviour they don't really understand. Children are sexual beings from birth—as uncomfortable as that may be for adults to recognise—and their curiosity around it is completely natural. They take pleasure from playing with their genitals, are deeply interested in other people's genitals, and have an endless appetite for stories or demonstrations of bodily functions. This is all healthy. So in a school environment, with all the duty-of-care implications that go with it, knowing where to draw the line can be difficult.

At Debbie's school, there's no school uniform, or, more accurately, no-one wears it. This means there's often the 'inappropriate dress' issue to deal with, as young girls copy what they see their older sisters wear, or friends' older sisters, or pop stars or movie stars or just images in magazines. Increasingly, teachers are also seeing boys wearing so-called 'muscle tees' to show off their gym-honed bodies. All of these kids, in one way or another, are anxious to look good. Body beauty still conforms to the old stereotypes: slender but busty for girls, ripped for boys. It's a difficult matter for teachers to deal with because on the one hand, they do not want children to feel embarrassed or ashamed of what they're wearing, but on the other hand, they have school rules to enforce. And did I mention this is all before the teachers get started on literacy and numeracy?

There's something not quite right about a society in which parents allow young children to watch pretty much whatever they want, yet baulk at the idea of Year 3 and Year 4 children receiving age-appropriate, research-based sexuality education. But that is what's happening, and schools are often wary of possible parental outrage when deciding when and how much sexuality education to deliver at the primary school level.

Sexuality education is a messy affair in Australia (as we'll explore in even more detail in Part IV of this book). It's part of the health and physical education program laid out under the national curriculum, which is overseen by the Australian Curriculum, Assessment and Reporting Authority (ACARA). Originally, ACARA included learning about puberty in the curriculum for years 3 and 4. But under pressure from Catholic schools, it pushed it back to years 5 and 6, when puberty is already well underway for many kids. The ACARA guidelines also have been watered down to satisfy parental concerns, and of course, over and above that, schools have the autonomy to run sexuality education as they please: they can do it in-house or outsource it to groups like Family Planning. Within the guidelines, they can do as much or as little of it as they please.

There is a strange confusion of attitudes in this. No-one is suggesting that children in years 3 and 4 learn about oral sex or abortion, but they should at least have some understanding of their bodies, including the correct way to talk about their body parts, and begin to have some awareness of the changes they will undergo in the next few years (or even, in some cases, that same year). Perhaps even more importantly, they should be learning about healthy, respectful relationships, how to be explicit about what they want and stand their ground in achieving it. Most people would acknowledge that it's better for kids to learn about their bodies, puberty and, eventually, sex from a teacher or a well-informed adult rather than from Chinese whispers in the playground or randomly from the internet. Yet there's also a school of thought that such learning is best done 'at home', an old-fashioned idea that sees these matters as innately 'private' (and, boy, how easy is the slide from privacy to shame) rather than something children have a _right_ to know.

The simple fact is that if telling children about puberty is left to parents, some kids will never learn anything. And the knowledge parents have of these matters may not be up-to-speed either, no matter how good their intentions might be in having 'the talk'—quite apart from the fact that the topic should not be covered in a one-off, embarrassed chat, but through ongoing, and hopefully open, discussion. It is a school's job to educate children about their bodies and their sexual maturation as much as it is their job to teach kids about long division. Both are important life skills. And the best way to address not only the false information but the general giggly embarrassment (from the adults as much as the children) is to start this education early.

Years 3 and 4 seem to be the right time to start talking to kids about puberty, even earlier for body awareness, correctly naming body parts and expressing emotions. It's no good waiting until a girl discovers she's bleeding one day and thinks she's dying—countless renditions of which you will hear from women who went through puberty just a few generations ago and had no idea what was happening to them because no-one thought it a suitable topic of conversation.

There does seem to be a widely held idea that if you talk to primary school kids about puberty, it takes away their innocence—the childish bubble they so happily inhabit. I understand this notion, but the thinking is wrong-headed. For a start, there is no evidence that teaching kids about sex is more likely to make them act on it. But more importantly, modern media and entertainment are so pervasive, and much of it is so innately adult, that children pick up ideas long before they discuss them with adults. Often, their ideas are wrong or misguided, so it is important to intervene early and make sure the information filling their heads is high-quality. And if parents can't or won't do it, schools should—in fact, schools should do it whether parents do or don't.

Some adults seem to worry, too, that children might be overwhelmed or frightened by the information. But it's hard to escape the feeling that the only ones who are frightened are the adults. If the information is well considered, reliable and—most importantly—age-appropriate, there's no reason why students would be unduly perturbed by it. Often, kids better understand and are capable of much more than we give them credit for.

Sexuality education (which I talk about in greater detail in Part IV) shouldn't just be about the nuts and bolts of reproduction, as it once was: the dour science teacher scribbling down facts on a blackboard, making liberal use of animal- or plant-based metaphors to get the message across. It is important to know the biology of sex and reproduction—and collectively we probably know too little—but what matters more for children is learning to navigate the difficult emotional waters of puberty, and coming into sexual maturation. Importantly, we need to give young people the sense of self to know what they want, the confidence to ask for it or refuse it, an understanding of how to manage any kind of relationship, and the resilience to resist pressure from others and withstand negative experiences.

Given the current debate around the Safe Schools sexual and gender diversity program, transgender issues and same-sex marriage, excellent sexuality education is particularly important for creating a safe and supportive environment for LGBTI (lesbian, gay, bisexual, transgender, intersex) young people. Puberty is a time of gradual sexual maturation: kids may start masturbating for the first time or more than they were, they may start dating, and they may realise they are lesbian, gay, bisexual or uncertain about how to characterise their sexuality at all.

Whenever I speak to parents about puberty, one of the biggest concerns, particularly for those who have daughters, is the sexualisation of young girls. And having a young daughter myself, I completely understand and share that concern. Has the marketing of 'femaleness' and 'maleness' ever been more aggressive than it is now? I doubt it. It starts even before birth and continues all through childhood and adolescence: girls get the message to be passive, pink and pretty, boys to be active and loud and strong. You only have to walk into a toy store these days to be overwhelmed by its pinkness for girls, the way every item seems to be accompanied by butterflies or fairies or ponies, while the boys are given pirates and trucks and dinosaurs. Boys and girls get locked into gender norms early on, and that pressure continues to be exerted throughout our lives. Young girls are being taught that their value rests in being looked at, such as when well-meaning friends or relatives say, 'Don't you look pretty today?'. We collectively comment far more on the way females look than males, and children absorb this from the start—and it matters that boys absorb it just as much as girls.

Despite being weirdly uptight about talking about sex, ours is a highly sexualised culture, and increasingly so. Sex is everywhere on television, in music and in films, and it permeates great slabs of the internet. Again, while there is certainly pressure—more so than ever before—on young men to conform to a narrow idea of 'hotness', that cultural pressure still falls disproportionately onto girls. That is why parents worry when their prepubescent daughters want to wear make-up and heels, or insist on wearing a bra-like crop top under their clothes even though they have no breasts to support. It is why parents tear their hair out looking for clothes for 'tween' daughters that don't make them look like a 25-year-old at a nightclub. It is hard to resist the power of marketing, and even harder to resist the nagging of children.

This is another reason why high-quality, consistent sexuality education matters—there's much to be gained from reaching young people before their hormones do. A good, effective sexuality education curriculum should encompass assertiveness—knowing when and how to say 'no' (and yes, for that matter)—and later on, dissecting media-driven images and ideas. And of course, when the time is right, it should include information about pregnancy, sexuality and gender, sexually transmitted diseases and anything else young people might want or need to know.

The hysteria over 'tearing down' childhood innocence with high-quality, age-appropriate information makes about as much sense as telling kids they were delivered by a stork. We need to overcome our own shyness, our sense of the innate privacy of puberty, and treat it as we would any other facet of education: as something that children have a right to know, and that we have a responsibility to tell them.
Chapter 5

**Hopscotch and Hormones**

Development in the Middle Primary Years

WE ALL KNOW how important it is to give babies and toddlers the best possible start in life. And there is endless information available to new parents—often conflicting but most at least well meaning—covering everything from breastfeeding to developmental milestones to early childhood education. We are instructed sternly on the importance of 'tummy time' for infants, to build their upper body and neck strength; of instituting good eating habits in the toddler; of encouraging literacy (but not forgetting numeracy) in the preschooler. We know that not only is the brain developing rapidly during this time, but that it has enviable potential for learning—a few months with a two-year-old will tell you just how quickly they catch on to things and remember them. But as adorable as small children are, they are also hard work. So there is often an unspoken sigh of relief when they reach the age of five or six and are entrusted to the care of the local primary school.

For a long time, it was assumed that during the middle primary years—that period between preschool and puberty—nothing much happened, that it was something of a latent developmental time. Sure, there was reading, writing and 'rithmetic, but it was assumed that these would otherwise be relatively calm years between the high maintenance periods of infancy and puberty. Well, it's time for a rethink. Some groundbreaking Australian research is turning that idea on its head.

The Childhood to Adolescence Transition Study (CATS) overseen by adolescent health expert Professor George Patton, which I introduced in Chapter 1, has shown that at around years 3 and 4 (about age eight or nine) there is a huge hormonal shift in children. This shift has a significant impact on children's relationships and their emotional wellbeing, as well as laying the groundwork, so to speak, for the physical puberty that will follow. And, once again, it has serious implications for how we handle the primary school years as parents and teachers, with the aim of helping children make their way into puberty proper and on to adulthood.

Patton has taken a particular interest in puberty and the transitions that occur during adolescence, including the implications these have for mental health, substance abuse, body image and risk-taking behaviour. This has led to the professor and a team of researchers from Melbourne's Royal Children's Hospital and the Murdoch Childrens Research Institute undertaking the CATS, a large longitudinal study of puberty. They recruited over 1200 students in Year 3 and, with the help of the children's parents, are charting their development all the way through puberty. That group of students completed Year 7 in 2016, and the CATS has already made some important findings.

As briefly described in Chapter 1, adrenarche is the first 'event' in puberty, a surge in male sex hormones (testosterone and others) produced in the adrenal glands—although they are at lower levels than they will be during puberty proper, when the gonads swing into action and pump out these hormones. While androgens are male sex hormones, they are significant in females too—especially testosterone, which is responsible for the growth of pubic hair as well as for the sex drive in women. They are also important precursors to puberty because the ovaries will later convert testosterone into oestrogen when gonadarche, or physical puberty, is in full swing.

Adrenarche in itself is not breaking news—scientists have known of its existence for some time, including its role as the warm-up act for puberty proper. But for a long time, little was known about exactly what happened during adrenarche, partly because one of its curious aspects is that there are no physical signs of it occurring. So short of screening for hormone levels, there's no way to tell if a child has started down that track. Now, however, technology like functional MRI scans is allowing researchers to gain insights into how this particular surge in hormones might affect brain function. And in particular, they are keen to know how that hormonal shift relates to the onset of gonadarche.

To help research this, the CATS team has taken regular saliva samples from the children to track their hormone levels, along with measurements such as their weight and height. They have followed this up with questionnaires for both the students and their parents, asking about behaviour, mood, relationships, and any physical changes that may have taken place. So far, the team has found that at about eight years of age, children experience a huge hormonal surge caused by the activation of the adrenal glands. And boys in particular who have higher levels of these androgens are more likely to have behavioural problems than those with lower levels, suggesting that these hormones may have a significant impact on certain aspects of brain function.

Adrenarche also appears to be a time when sex differences make themselves known. While puberty proper tends to have a bigger impact on girls than on boys, for adrenarche the converse is true: boys appear to be more affected than girls.

While writing up some of the early findings from the CATS work for a feature article in _The Age_ in January 2015, I visited a primary school in Melbourne's inner north which is involved in the study. There I met upper primary teacher Catherine, who had taught the same group of kids in years 3 and 4, when they had been recruited for the study. Catherine told me that the CATS findings resonated strongly with her classroom experience: that around Year 4 in particular, kids started to change. They were more emotional, more fractious, and their friendship groups started to shift, often for no obvious reason. 'I would say in about 90 per cent of kids you see emotional changes before you see the developmental stuff', she said. 'You can tell there are emotions, but they don't know what those emotions are.'

I decided to go back to the school to have another chat with Catherine when I was writing this book, to see how her students were faring and if she had reflected any more on the CATS findings.

Catherine is strikingly tall, with a calm, kindly and sensible manner—the kind of teacher you just know kids would love. She knows what a big impact puberty can have on a young person, having gone through it early herself. She had her first period at the end of Year 3, and at that point was already standing head and shoulders above the other kids, well on her way to reaching her full height of 188 centimetres (6 feet 2 inches in the old money). (It is unusual to end up so tall having started puberty so early, but more on that later.)

Catherine's mother was a schoolteacher who assumed that, like her, Catherine was likely to go through puberty early, and so had prepared her daughter accordingly. When Catherine started to grow rapidly in Year 2, there was no doubt that it was happening, and the following year, she started to menstruate long before her friends. Understandably, it was all a bit of a shock to such a young girl. 'I still thought I was dying', Catherine recalls, 'even though Mum had told me what was going to happen'.

And so now, teaching a Year 5 class, Catherine is acutely aware of what some of her students are going through, or about to go through. She has noticed, though, how much easier it is to teach Year 5 kids than to teach children in years 3 and 4, which she puts down to that sharp rise in hormones around adrenarche settling down, or at least students coming to terms with it. She notices it particularly in the boys.

What's going on with boys? Why would this affect them in particular? Psychologist Lisa Mundy, who is helping lead the CATS work, tells me that researchers are not entirely sure of the answer to this just yet: they are working to some extent in unchartered territory. And it's not just about the levels of hormones, either—around the time of adrenarche, levels of testosterone are actually higher in females than in males. What researchers suspect, though, is that they are beginning to see distinct differences in how the brain reacts to the surge of hormones—differences along gender lines. Although girls are also affected by adrenarche, it is more pronounced in boys.

Androgens, the hormones at work during adrenarche, are known to be associated with behavioural and mental health problems. There is something of a chicken and egg debate in this: it may be that young boys who have social and behavioural problems are more likely to have higher levels of these hormones (and adrenarche simply acts as a spur to this), or it may be that adrenarche itself elevates the risk for these problems. In any case, as mentioned earlier, boys who do have higher levels of these male sex hormones during adrenarche are more likely to have such problems, which may have huge implications for intervention at this younger age to prevent the escalation of serious mental health problems through adolescence and beyond.

This shift in middle primary years—with kids' emotional and social lives being shaken up to some extent—makes sense to Year 3 teacher Kathy, too. She teaches at a large private school in an affluent bayside suburb of Melbourne, and has noticed that something changes in that year. To her it is actually the girls who show the most significant disruptions in their friendship groups, and a sudden realignment, as though they are trying to figure out who they are and where they stand on the social scale. She doesn't notice this in the boys so much, but what she does see is them starting to respond to peer pressure: that previously 'good' boys are now far more easily led astray by the 'naughty' boys.

There's certainly something that happens to children at this stage, even though none of them, as far as Kathy has noticed, are starting to go through puberty proper just yet. In fact, they change for physical education in the classroom in front of each other—she sees absolutely no self-consciousness among the students at all. So it may not be that gonadarche has come calling just yet.

About 30 kilometres east of Kathy's school, Fiona teaches a Year 3/4 class at a reasonably large government primary school. She has been a primary school teacher for over 25 years, and has long observed that the jump from years 1/2 to 3/4 is a big one for students, both academically and emotionally. But there's something else she's noticed, which she puts like this: 'I think, generally, Year 3/4s are a lot older than they used to be'.

This is an intriguing comment, one that resonates with observations other primary school teachers and principals have made to me. What is meant by kids seeming _older_ than they used to? Well, it's a kind of self-awareness, a knowingness and an assertiveness, all of which are good qualities in the right context (and amounts). Kids of this age simply seem to know more—no doubt because of their access to the adult world through technology, but also through conversations and daily living—than they used to. Kids have a lot of power these days, and often a strong instinct about how to use it.

Asked whether she thinks kids in general are going through puberty earlier than they used to, Fiona doesn't hesitate. She has no doubt that girls (she doesn't notice it so much with the boys) are developing earlier. She's struck by how tall they are and how often she sees other signs of puberty weaving its magic: greasy hair, for example, or a bit of body odour. Primary school kids watch television shows aimed at teenagers, she says, and they are already suffering some of the anxieties of body image that are usually the hallmarks of adolescence.

Where does all of this leave primary school children in terms of puberty? There are two key things going on. Firstly, girls in particular are starting puberty earlier, and secondly, all children are prone to a kind of cultural adolescence, exposed to ideas, images and concerns that are far beyond the longstanding norm for their chronological age. Physical change and social change are happening earlier, and emotional change gets taken along for the ride. Some children will not be ready for this; others will think they are but may be mistaken.

We have to come to grips with this. When boobs and pimples and BO are joining in with the kick-to-kick and Shopkins, something has to change. We need to know much more about what is happening to children on a physiological level, including how big a role environmental toxins might be playing in the earlier development of girls, and whether they affect boys as well. And we need to think far more carefully about how much we allow children access to the adult world ahead of their time, even inadvertently. We can't fret about how learning the difference between a penis and a vagina might strip away their childhood innocence, yet happily let them engage in entertainment that is heavy with violence and sex, without having the same concerns.

It would be foolish to think we can effectively curtail children's access to these ideas and images, so what we need instead is counter-messaging, which opens up a discussion about what they have heard or seen, and also calmly offers sensible, accurate information in its place.We also need to let young people know that they can discuss anything that worries, confuses or upsets them without fear ofjudgement.

More immediately, we have to use that wonderful resource that all families of young children have at their disposal: school, and more specifically, sexuality education, as discussed in Chapter 4.

Puberty can be a tough time, and even when it's not, it is still significant. It changes the body and the person. It has tended to segregate girls and boys more specifically than the pre-pubertal world, and eventually it introduces sex and sexuality. Through all of this, boys and girls will head off on different trajectories of change, beholden to large amounts of sex hormones in proportions related to their gender and combined with long-established, heady and deeply persuasive cultural forces. Then there's their families and the social context in which they are growing up. It is a time when mental health issues can come to the fore, when self-esteem can plummet, and when risk-taking can override good sense.

Our key defence to all of this is information and communication, because how girls and boys experience these changes, and the challenges they raise, lays vital groundwork for the adults they will become.
II

Girls and Puberty
Chapter 6

**What's Happening to Me?**

_I got my period when I was 10 years old. I didn't even know what a period was. I had sexuality education so I knew where babies came from, but no education about puberty._

Mandi, 28

_It was a confusing, embarrassing and somewhat stressful time for me, but not horrifically so. I remember being given a book about puberty, but there wasn't a huge amount of conversation within the family about it. More would have been good, probably. I must have felt uncomfortable with the changes in my body on some level, as I developed anorexia around age 14. Other factors were no doubt at play, including personality traits and personal circumstances, but I suspect that societal unease around female sexuality and body image was tied in there somehow._

Meg, 45

MANDI AND MEGAN'S comments are typical of the responses I received to my (admittedly non-scientific) Facebook survey of how people felt about puberty—both their own and their children's. The word 'awkward' came up a lot, while 'embarrassing' also seemed to roll off the keyboard. But most of all, people talked about it being something like unknown territory, of how little information they received or, as a friend of mine put it, that 'there was a prevailing sense that certain topics were off-limits'.

Why should this be so? What it is about puberty that makes adults collectively so uncomfortable, so unwilling to talk to kids about it, and in some cases, so unwilling to have kids hear about it at all?

Puberty flashback #263: I'm in Year 8 at my all-girl school, struggling to take off a particularly tight-fitting pink leotard from underneath my uniform so that I can go to the toilet. I was wearing the leotard because I was yet to come to terms with the small breasts that had recently made themselves known—when I wore the leotard under my uniform, I looked completely flat-chested. Many women, I know, would have the opposite memory of puberty and their breasts: of trying to make them bigger and more noticeable. But not me. Ballet, and its weird relationship with female bodies, had been messing with my head again: curves, breasts, body fat, underarm hair and general womanliness all contradicted its strict aesthetic. I had absolutely no ambition to be a professional dancer—I didn't have the passion for it, and I was also aware of my very real physical limitations—but I had managed to absorb these messages anyway. It would've helped me, I think, if someone had told me that puberty was healthy and normal, not something to be embarrassed about. But there I was, wrestling with my uniform in a toilet cubicle, trying to pretend it wasn't happening.

It's a puzzling cultural anomaly. On the one hand, we live in a diverse, largely secular society that prides itself on an overweening sense of small 'l' liberalism: the 'live and let live' philosophy has long had a strong foothold in Australia. But when it comes to young people and sexuality—particularly them coming into their own—we seem trapped in a kind of archaic conservatism, a sense that you don't talk about that kind of thing, that there is something innately embarrassing and even dirty about certain aspects of puberty. Menstruation, of course, is the stage that seems to attract the most squeamishness.

Are we more hung up about the female body than the male body? I think there's little doubt that we are, and that female sexuality has long been viewed with a mix of suspicion, wariness and disgust. Or even historically—and I hope this idea has long since been put to bed, so to speak—believed not to exist at all.

Let's just take one small example of our discomfort with the female body: how we talk about our genitalia. What is it that we females have, exactly? 'Vagina' is an anatomical term, the name for a small part of women's genitalia that has come to represent the whole. In some circles it is referred to as a 'fanny', the term most often used when I was growing up, but which has a certain coyness and daggi-ness about it that makes me uncomfortable. (And who among us, as children, didn't find it hilarious that two of the author Enid Blyton's most beloved characters were Dick and Fanny?) Far worse, though, is 'front bottom' (the _what_ now?), 'down there', 'nether regions', 'privates', 'your bits', 'lady parts' or any other terrible euphemism. 'Cunt', of course, is a difficult one to roll out to a two-year-old or a GP, so imbued is it with misogyny and abuse, despite a concerted effort by women to reclaim the word. It is instructive that one of the strongest terms of abuse we have in the English language—one of the words most likely to make even accomplished swearers, particularly females, cringe—likens someone to female genitalia.

When we talk about male genitalia, we have 'dick', 'cock', 'freddy', 'willy', 'knob', 'schlong', 'wang', 'member' and countless other names that have made their way into the vernacular. (So many are boys' names. Perhaps we women should start calling our vaginas Hermione or Beatrice or Beryl. Or rethink Fanny.) They all have reasonably affectionate undertones—none of them carries anywhere near the cultural load of 'cunt'. And while we're still far from comfortable talking about it, rarely is male genitalia referred to as 'down there' or 'man parts'. But with females, we struggle, and it is symptomatic of the problem as a whole.

One of the issues that arises when we talk about male–female sexuality is the dated assumption that can undergird it: that men are sexually voracious and can't help themselves, as opposed to women, who don't want sex nearly as much, and that it's up to women to take responsibility not only for themselves but for men as well. This is the viewpoint that informs a lot of the 'slut shaming' rhetoric that sadly gets a regular outing. It is also one of the reasons why the federal government's recent 'Stop it at the start' advertising campaign, which blew apart the 'Boys will be boys' approach and pointed out that these attitudes are instilled from a very young age, was so effective.

Again, our language is instructive. Think about the term 'mistress' and how it is still widely used to describe the female lover of a married man. It is a word laden with fear and contempt: she's got him by the balls, literally and figuratively. But there is no equivalent for men. We may have come a long way, baby, but—in almost every facet of our lives—there is still a long way to go.

These things are deeply entrenched in our minds and our anxieties, often unconsciously so. Part of the problem we collectively have with girls reaching puberty—and the younger they are, the more heavily it weighs on us—is the notion that gaining an adult physique makes them vulnerable. This is a perfectly legitimate concern to have regarding, for example, a 10-year-old. How could she possibly cope with teasing about her boobs when she's still playing with My Little Pony? And it's one thing dealing with other kids, but how vulnerable might it make her to unwanted sexual interest or even assault from someone much older? We live in a time of high cultural anxiety about these matters—anyone who has tuned in to the Royal Commission into Institutional Reponses to Child Sexual Abuse and heard the survivors' harrowing stories, for example, cannot help but be deeply troubled by them. At the same time, we are increasingly hearing reports of sexual harassment and sexual assault on university campuses, so much so that the peak body Universities Australia has asked the Human Rights Commission to investigate.

When it's not the concern about a girl being subjected to a sexual context for which she is not ready, there's the issue of how she may be treated because she looks older than she is. That is, adults, or even other kids, may expect more of her simply because she no longer looks like a child—even though, of course, she is one.

Here's another problem: as adults, we may not know that much about puberty ourselves. Just as a parent feels befuddled when their child presents maths homework and they are left frantically trying to blow the dust off some ancient information in a remote archive of their brain (while also cooking dinner), so too can our knowledge of the exact function of body parts—and our ability to convey that knowledge in an age-appropriate way—leave us floundering. It's easy to leave a reputable book on your children's beds (and there's no shortage of excellent books about puberty written for kids) and hope to god they don't have too many follow-up questions. It's far harder to do the research, brush up on your knowledge, and then initiate a conversation that is frank and open but not too excruciating.

And there's one final, subtler, but no less persuasive factor in our collective silence: just how difficult it can be sometimes to acknowledge that your kids are growing up—and that they are sexual beings. The anxiety around this is a natural corollary to being a loving parent: If they grow up, what will happen to them? Will they be OK without their mum and dad hovering over them? And, hey, if they're getting older, doesn't that mean we are too? All this can trigger a melancholy moment—if I had a dollar for every time a parent told me, when I had my baby, to enjoy every moment because they 'grow up so fast', I'd probably be sunning myself on a Tahitian beach right now—and a reminder of life's quick progress, the way it seems to gather pace with each passing year.

In growing up, our kids start to move away from us, develop independence and figure out who they are separate from their family environment. Add in the social changes that can happen around puberty, when young people instinctively become more private (certainly less communicative with parents) and far less predictable than they once were, and it's a bewildering time for Mum and Dad.

But the approach of not talking about something and instead hoping it will go away has proven, on so many issues, to be a profoundly unsuccessful one. Puberty is no exception. A girl is more likely to cope well with puberty if her parents, teachers and society more generally have encouraged her to be confident, assertive, resilient and well informed, and to become friends with confident, assertive, resilient and well-informed boys.

So what happens to a girl when she reaches puberty, which as we know might be anytime from the age of eight to 14? Pubertal change tends to follow a standard chronology, starting with breast buds and ending in menstruation, but once again there can be a lot of variation in this—girls, for example, may also experience an increase in sweat and body odour during puberty—that is completely normal.

**Breasts**

Usually the first cab off the pubertal rank, breast buds start with just a slight swelling of the nipple area. They can be hard and painful, and it's very unpleasant to be hit in the breast once puberty starts, as alert readers of Chapter 1 will recall. However, any tenderness is likely to dissipate as the breasts develop. (Although hormones can affect breast tenderness throughout adult life, and particularly so in the lead-up to a period or in pregnancy.)

In the earliest developments, the nipples will stand out, and the areolae (the pink, circular areas around each nipple) will darken and become bigger. As the ovaries produce large amounts of oestrogen, fat in the connective tissue accumulates and the breasts 'bud'. Once a girl's periods begin, the breasts continue their maturation (in fact, breasts change all through women's lives), and the duct system develops in preparation for childbirth and breastfeeding.

It is quite common for one breast to grow more quickly than the other, something that will likely even itself out as puberty runs its course (though it is very common for adult women to have some slight breast asymmetry). As with most aspects of puberty, a look at the gene pool will give some indication of how a girl's breasts will develop and to what size: big and small boobs (and average ones, for that matter) tend to run in a family.

**Pubic Hair**

While breast development is usually the first sign of puberty proper, pubic hair can make an appearance beforehand or at the same time. It most often appears shortly after the breast buds, beginning as fine, fair, downy hair and becoming darker and coarser as puberty continues. There is no consensus about the evolutionary purpose of pubic hair, but the most widely held view seems to be around protecting the delicate skin underneath from friction or abrasion, and helping to keep bacteria and other microbes at bay.

Hair removal is another politically contested area, with one view having it that hair removal is part of the cultural pressure on women (in many Western societies, at least) to conform to a certain aesthetic ideal—yet another way in which women are coerced into feeling bad about their bodies. In terms of health, it has been suggested that ripping hair out increases the risk of infection via bacteria entering the follicle. Ultimately, hair removal is a matter of culture or personal preference (or, if you are an elite athlete, of shaving milliseconds off your times). The grooming of pubes has been around for centuries and has followed tides of cultural fashion, with the most recent trend towards female pubic hair removal starting after World War II and continuing unabated since, at least in Australia (some European countries, on the other hand, have a more relaxed attitude to pubic hair, and to their bodies more generally). Most people remove or keep hair for such cultural reasons, or aesthetic reasons, or because they think it enhances their sexual pleasure and/or attractiveness (or, if they are like me, because they can't be bothered shaving in the cooler months).

The dark side of all this is pubic hair's association with disgust—that it is not feminine to be hairy, that it's unattractive. Or more fundamentally, that women's bodies in their natural state are not acceptable, which is the reason we dye our hair and wear make-up, or undergo cosmetic surgery. An Australian study published in 2004 and involving 107 female undergraduate students found that 98 per cent of them removed their leg and/or underarm hair, mostly by shaving. It is the norm these days, and beauticians do a roaring trade in Brazilian waxes.

**Pimples and Acne**

The androgens or male hormones that swing into action during puberty change the skin.They make it oilier, stimulating the sebaceous glands to produce more sebum, which along with excess skin cells can clog the pores and trigger the growth of acne bacteria. This happens alongside inflammation of the skin and produces pimples—a kind of minor infection or inflammation. As someone who developed adult acne and still struggles with it, I know how strongly it can affect self-esteem. Plus, it hurts! Cystic acne in particular—the deep, large and painful pimples that last a long time—can be very distressing. Mostly, acne will clear up as the hormonal surge settles down, but if not (again, this is likely if it runs in the family), a GP or dermatologist might suggest an antibiotic or stronger medication to clear it up. Acne (as opposed to occasional pimples) can leave scarring on the face and body, so if this is prominent in your child, or if it's causing her or him distress, it is worth seeing a doctor.

The relationship between diet and acne is a complex one that remains hotly debated, even among scientists. It was long thought (and dutifully passed down from parent to teenager) that a high-fat, high-sugar diet caused acne. That thinking changed. It's now believed to be mostly about hormones, specifically testosterone, to which the skin of some people responds badly. Nonetheless, having a healthy diet and exercise regime, and drinking plenty of water—things that are important for a person's overall health—can help keep skin clear. Oh, and that warning not to squeeze pimples because it can spread infection? That still stands.

**Vaginal Discharge**

Of all the mysteries of puberty, this is the one we hear about the least, probably because it's the one most likely to elicit a response along the lines of 'Ewww'. Of course, it's just a perfectly natural and healthy part of the body's transition from child to adult. About a year before a girl reaches menarche, there will be an increase in a white or yellow discharge from her vagina. This is due to a change in hormone levels: the discharge keeps the vagina clean, and it will continue after menstruation begins. Usually a girl will notice it in her underwear and it won't be a big deal. But it is important that girls know about it, expect it, and understand that it is normal and healthy. The only exception is if the odour is particularly strong, or the discharge is accompanied by itching or burning, in which case there may be an infection and this will need to be checked by a doctor.

**Body Shape**

As the female body moves from childhood to adulthood, our good friend oestrogen prepares the body for eventual childbearing by widening the hips and depositing fat there. A girl going through puberty will, in time, start to look curvier than she once did—she will start to look, logically enough, like a young woman. The gorgeous curves of womanhood are something to be celebrated and not thought of as 'my bum getting big'. The more we can drive that message home to young girls—not just during puberty, but always—the better will be the relationship they have with their bodies for the rest of their lives.

**Growth Spurt**

As with all facets of physical development during puberty, girls will typically experience a growth spurt before boys, leading to that sight of Year 6 girls towering over their male peers. Eventually, boys have the growth spurt too, and on average grow for longer and end up taller than their female classmates. Girls usually reach their full height by age 17, while for boys it is 19, or a little later. At their time of peak growth (around 11–12 years of age), girls shoot up by 6–10 centimetres a year.

Young people often find that they become a little clumsy and physically awkward at this time, as though their bodies have grown so rapidly that they can't control them. A girl's body parts won't grow uniformly—the head, hands and feet tend to grow first—so for a while, certain parts may seem a little out of proportion, and it may take some time to adjust to that. In the meantime, lock up the good china.

**But wait, there's more...**

All of this leads up to the main event of female pubertal change. It is usually puberty's last stop, and there is probably no other aspect of human sexual development that is spoken of as frequently, or with such a potent mixture of fascination and repugnance. It has long been considered a private matter, but that 'privacy' has too often slid into shame. It has been linked to the cycles of the moon, and a sense of female 'otherworldliness' and mystique, and it has been roundly complained about when advertisements talk about it too frankly. It has been handled in a variety of ways in pop culture—often through uncomfortable humour imbued with fear—and linked with female moodiness, irrationality and even madness. Women have been just as guilty of all this as men, yet without this monthly phenomenon, human beings would cease to exist.

Ladies and gentlemen, I give you menstruation.
Chapter 7

**Period Drama**

Our Struggle to Deal with the Bleeding Obvious

_My parents were separated when I got my period at 11, so Mum had to call Dad to tell him to put a bin in his toilet. He refused because it was 'gross' and he didn't want to have to empty my 'period bin'._

Sally, 27

AS MUCH AS would like to believe that Sally's experience is an isolated one, I know that it is not. Just about every woman could tell you a story about embarrassment or disgust around their periods—even if it was her own.

The uncomfortable truth is that most of us feel a profound discomfort with menstruation and the female body, which has an equally profound impact on young women as they develop into adults and beyond. We never quite seem able to come to terms with the fact that women bleed once a month, nor with how much unnecessary fear and anxiety surrounds menstruation. No matter how broad-minded or cool we think we have become, we just haven't been able to shake this.

This is hardly unique to Western culture. So profound can this discomfort be that, in some cultures, menstruation is handled with inconceivable brutality. _The Guardian_ newspaper, for example, reported in late 2016 that a 15-year-old Nepalese girl had died after being banished to an animal shed during her period—it's thought the girl suffocated after lighting a fire in the poorly ventilated building to keep warm. This is part of the ancient Hindu Chhaupadi system, according to which menstruating women are sent to animal sheds while they are bleeding because they are considered 'impure'. The practice was outlawed in Nepal in 2005, but it seems to have continued in the remote western region of the country. This is obviously an extreme example of discomfort with menstruation, yet it's a sobering (and tragic) reminder of how much work is yet to be done.

Menarche—a girl's first period—usually occurs after all the other pubertal development is in train, and pubic hair and breasts have made themselves known; it occurs in the latter stages of puberty. As described in Chapter 2, menstruation is triggered by the brain's hypothalamus sending out increased doses of gonadotropin-releasing hormones (GnRH) to the pituitary gland just beneath it, which in turn sends its own chemical messengers, follicle-stimulating hormone (FSH) and luteinising hormone (LH), to the ovaries. That's when the ovaries start to increase the amount of the female sex hormone oestrogen that is coursing through a girl's body.

There are in fact many different types of oestrogen, but the key one in play here is called oestradiol. When oestradiol increases, the lining of the uterus—the endometrium—thickens in preparation for supporting a pregnancy further down the track. I say 'further down the track' because a girl's first few periods are usually anovulatory, which means that no egg is released from the ovum, but other parts of the menstrual cycle are in place. Think of it as the body's dress rehearsals before the main event.

If the thickened endometrium is not needed for a pregnancy, it is shed—blood, cells and mucus are expelled from the uterus wall. Within five years after her periods start, a girl will usually start to release an egg each month (mostly, just one egg is released, although sometimes there are two, which is why some couples end up with non-identical twins). However, it is common for girls at the start of their menstrual lives to have irregular periods for some years, before reaching peak fertility at about age 18.

A menstrual cycle is said to start on day one of a woman's period, and regular cycles are defined as 25–35 days, with 28 days being the most common length. Irregular or longer cycles reflect less organised and regular ovulation. Once the menstrual cycle is established, it has four phases. Phase one is menstruation, which usually lasts 5–7 days but can be shorter or longer than that, without any cause for concern—a woman's cycle will fluctuate throughout her life, depending on diet, stress, age, weight and exercise levels.

Phase two is the follicular phase, when the FSH stimulate the follicles (tiny, fluid-filled sacs that grow to about 1 centimetre at ovulation) on the ovaries to start maturing the eggs they hold inside them. While this is happening, the ovaries are also pumping out more oestrogen, which is thickening the lining of the uterus. Once an egg is ripe for release, ovulation occurs, which is phase three of the cycle. The day before and the day of ovulation are the best times for women to become pregnant, as it's the easiest part of the cycle for sperm to make their way to the egg, and for one lucky swimmer to gain entry. Therefore, it is also the most important time for couples who do not wish to have a baby to be particularly vigilant about contraception (that means you too, men).

It is the abrupt rise in LH, mentioned earlier, that triggers ovulation. Some women experience pain or discomfort at this time, but many do not notice it happening at all. After ovulation, the egg makes its way down the fallopian tube, which is attached to the ovary, and heads towards the uterus. If it is not fertilised on the way, it usually breaks down and is absorbed into the lining of the uterus, which is then expelled when the woman has her period.

While we are in the most fertile time of the cycle, a word about cervical mucus. Most women will notice mucus at some point during their cycle: the texture, colour and even odour of the mucus changes according to the degree of fertility, so it can be a good signal to a woman hoping to conceive of their most fertile time. Doctors talk about the 'egg white' type of mucus as flagging the greatest fertility. This mucus, whose elasticity means it can be stretched between the fingers without breaking, best enables the sperm to reach and fertilise the egg.

During the luteal phase—the last of the four phases of the menstrual cycle—the ovaries pump out progesterone, which helps to support a potential pregnancy by firming the endometrial lining and the cervix. It's during this time that women can experience premenstrual syndrome (PMS), when the progesterone–oestrogen combination causes tender breasts, tiredness, tearfulness, bloating and/or fluid retention. Good times! It's about now that women can feel as cranky as a bag of ferrets, with no obvious external trigger, all because of the powerful hormones at work. But despite its physiological basis, PMS has become code for irrational, unpredictable women who take out their crazy on all those around them, eliciting responses such as: 'What, are you on the rag or something?' Yet another reason why menstruation is often treated with wariness and contempt.

In clinical terms, there is a group of women for whom PMS is not just run-of-the-mill menstrual discomfort but deeply distressing and painful, to the extent that it can significantly interfere with their wellbeing. And there is no real consensus about how to treat this: a gynaecologist can only suggest treatment according to the patient's particular symptoms and preferences.

In her paediatric gynaecological practice, Dr Charlotte Elder treats many adolescent girls experiencing problems related to their menstrual cycles. She says that cyclical symptoms like PMS become a clinical diagnosis—and worth treating—when they interfere with a girl's daily life. For example, some girls find that chronic conditions such as type 1 diabetes, epilepsy and bowel disorders can be exacerbated by their menstrual cycle. For other girls, the onset of menstruation can bring with it terrible pain and diarrhoea, because the prostaglandins and cytokines—hormones that are active during menstruation, causing the uterus to contract and expel the menstrual blood—have upset the digestive tract (they are also implicated in a lot of other unpleasant menstrual side effects such as nausea, constipation, vomiting, fainting or looking pale).

Those are the nuts and bolts of the biology of menstruation. The place it occupies in our collective psyche is much larger and more complex, cutting across our discomfort with blood and bleeding, and, as we'll discuss a little later, a fear of women's bodies and sexuality. The upshot is that having a period, which is as natural as breathing, has become shrouded in secrecy, silence and, in some quarters, shame.

To understand why this is so, let's go back to the physical discomfort that, for some women, can be a monthly nightmare, keeping them indoors and miserable for days at a time. When an egg has not been fertilised and a pregnancy does not have to be supported, the uterus, a strong muscle, contracts to dislodge and expel the endometrial lining. For some women, the pain is horrendous—dysmenorrhoea, or severe menstrual pain (which we talk about in the next chapter), may be diagnosed. But in many cases, the pain is eased by anti-inflammatory medication or analgesia such as paracetamol. Many women also find that a heat bag on the abdomen helps to relax the muscles.

The pain associated with menstruation—along with the clear product of it in terms of bleeding—has helped to medicalise or even pathologise in the public imagination what is a perfectly natural process. That is, having a period has become something that is _wrong_ with a woman, something that explains the crankiness and moodiness that otherwise has no rational explanation. There is an episode of the fine US sitcom _Modern Family_ that illustrates this very clearly. All three of the Dunphy women—Claire Dunphy and her two daughters—are menstruating at the same time, which Claire's husband Phil twigs to when observing them being overly emotional, irrationally angry and uncharacteristically scatterbrained, respectively. The gag runs along these lines: women go a bit crazy at that time of the month, amirite? And it's hilarious... and terrifying: Phil refers to the synchrony of periods in his house as 'Satan's trifecta'.

One of the greatest insights into the cultural position something occupies is the language used to talk about it. In the case of menstruation, euphemisms abound: some coy, some slightly accusatory, in keeping with the repulsion that so often surrounds the subject. 'On the rag' would have to be one of the more aggressive, while 'flying the flag', 'a visit from Aunt Flo', 'riding the crimson wave', 'the curse' and 'that time of the month' are among the more popular winks and nudges. A 2015 online survey conducted by the Germany-based women's health group Clue in association with the International Women's Health Coalition, spanning 190 countries and gathering more than 90 000 responses, found that euphemisms for menstruation exist across languages in every part of the world, indicating just how pervasive is human discomfort with it.

As an aside, the survey was conducted soon after Donald Trump brought menstruation into public debate in the United States and beyond. In August 2015, while taking part in a debate as a candidate for the Republican presidential nomination, Trump was pressed by Fox News host Megyn Kelly on sexist comments he had made in the past, against which Trump railed. Later, in an interview with CNN, Trump said, 'You could see there was blood coming out of her eyes, blood coming out of her whatever'. It was a classic gobsmacking Trump moment, where many listeners thought, 'Hang on, is he suggesting that her questions were irrational because she had her period?'. After the storm around the comments broke, Trump did not back down, instead insisting that he meant she had blood coming out of her _nose._ I'll just give you a moment to digest all of that. Right, on we go.

Of course, menstruating women have long been accused of irrationality or just plain madness. Because menstruation follows the monthly cycle, it is often associated with the waxing and waning of the moon, and perhaps that is where the link to 'madness' comes from—lunacy in the literal sense.

In her work as an historian at the University of Melbourne, Carla Pascoe has devoted a great deal of time to studying the history of menstruation and its products. Talking about menstruation is a taboo that has proved difficult to dispel, she says, even in the modern world where young people in particular like to think they are frank and open about everything. In fact, menstruating women have been the subject of a number of strange myths, with one persistent idea being that their monthly bloodletting gives them magical powers; for example, their touch can make flowers wilt, or turn wine to vinegar (now if the converse were true, that would be a skill well worth having).

When Pascoe went to research how menstruation has been talked about over the past century, she came across a major problem: there was hardly any information about it. Why? Because we don't like talking about it. (And a related problem is that very few researchers have studied it.) On and on the cycle goes. Despite this, Pascoe did discover some interesting things about Australia's first sanitary pads.

In 1925, the US company Kotex manufactured the first commercial 'sanitary products', which became available in Australia in the 1930s. The story goes that French nurses treating wounded soldiers during World War I discovered that 'cellucotton', a kind of soft gauze, could be used as an effective pad. An advertisement from 1926 shows a mother talking to a daughter under the headline: 'A Great Hygienic Handicap that Your Daughter will be Spared' (note the exciting use of capitals for emphasis). It exhorted women to 'begin the Kotex habit' and to 'note the improvements, mental and physical, that it brings'. The ad does not mention blood, menstruation or periods; rather, the whole narrative is about women concealing their shame and countering any embarrassment. Menstruation is a _problem,_ you see, and Kotex has the solution.

In oral history interviews with Australian women, Pascoe learnt that, at the time they were introduced, very few women used these pads. That's because they were prohibitively expensive—one pad cost about the same as a loaf of bread. So women continued to use homemade rags, which they washed out, boiled to disinfect them, and hung discreetly on the clothesline (they didn't want anyone, particularly any men in the house, to have to see them). It wasn't until the 1940s that commercial sanitary products became more accessible and widely used, in part because the women who worked for the Department of Defence during World War II were given them for free.

Pascoe subscribes to the anthropological view that our aversion to menstruation is a primal impulse related to our fear of blood, so clearly is blood associated with pain and death. But she also believes there is a fear of female sexuality—more specifically, female power—tied up in it. Women are associated with reproduction, and with the miraculous ability to develop another human being inside their own bodies, and menstruation is a monthly reminder of this. Women bleeding in a natural and necessary way, which is something that men distinctly do _not_ do, is a very obvious sign of their fecundity and reproductive power. Perhaps it is a fear of that power that has driven menstruation into the realm of secrecy and silence.

One of the boasts in that early Kotex ad was that their sanitary products ( _sanitary_ is an instructive word here, the inference being that bleeding is dirty and must therefore be cleaned up) could conceal any odours due to a 'new secret disinfectant', offering 'amazing protection' for the menstruating lady. Again, this is about offering reassurance: no-one will know your little secret!

How times have changed, right? Well, no. For many decades now, the marketing of feminine hygiene products—or 'fem-pro' advertising, as it is known in the industry—has walked a thin line between 'Hey girls, periods are cool and fine and you can get on with your life if you use our products' and 'Hey girls, make sure no-one knows that you're menstruating. Imagine how embarrassing it would be if you were caught out!'.

When I was a kid in the 1980s, ads for tampons and pads seemed to involve a lot of beach-going and a truly surprising amount of horse riding. The idea was that having your period was no impediment to having fun, and in particular being active. But the other, subtler message was: 'Relax girls, your secret is safe with [insert product name here]'. I also remember the distinct discomfort of some of my family members when these ads came on: 'Oh, do we really need to hear about this?' Fast-forward 30 years to 2015, when I decided to write a feature article on women's menstrual discomfort for _The Age._ During the research for that piece, I discovered that it wasn't until 1985 that a Tampax ad, featuring a young Courtney Cox of _Friends_ fame, mentioned the word 'period' for the first time in the fem-pro realm. 1985! No wonder we've all got so many issues about it.

Advertising offers an interesting insight into the broader cultural approach to women's bodies in general and menstruation in particular. Every six months, Australia's Advertising Standards Bureau (ABS) releases a list of the 10 most-complained-about ads for that half-year period. Ads for pads, tampons and panty liners make regular appearances in these lists. In fact, ads for menstrual products have made the top-10 list for five of the past 10 years, and in two of those years there were two menstrual product ads in the top 10.

The one that hit number one in 2012 was a television ad for Acti-Fresh panty liners. It featured an all-white room in which a naked young woman, her breasts and genitals concealed by artfully arranged furniture, had a frank girl-to-girl chat about how panty liners are an important part of keeping oneself nice between periods. She mentioned the word 'vagina', which raised the hackles of ABS complainants, but it seems it was the word 'discharge' that made viewers particularly uncomfortable. It is interesting, too, that it was women who seemed to do much of the complaining.

'There are some realities about womanhood and natural female cycles that should remain understood without being spewed into the home or public places through insensitive and offensive advertising', wrote one complainant. 'I object to the use of the words vagina and particularly vaginal discharge on television', said another, adding: 'My husband and I were so shocked we just stared at the television in disbelief. The use of a naked woman is completely gratuitous as well'. The outrage is telling: we don't like talking about vaginas at all, much less their intimate, messy functions.

I'm not having a go at advertisers here: they are selling a product; they are not directly responsible for upholding societal standards. Women need menstrual products, and advertisers are simply doing a job for the companies that want to sell them—at times quite deliberately courting controversy, drawing on the 'any publicity is good publicity' school of thought. But advertising both reflects social mores and reinforces them, and in the case of pads and tampons, it runs primarily on the idea that menstruation is problematic and should be kept secret.

Many people might point out that menstruation is a bodily function that involves the production of waste, and that we merely have the same instinctively disgusted attitude towards it as we would to, say, faeces or phlegm. This is a legitimate argument. But there are two key differences with menstruation: it only happens to half the population, along gender lines; and it is clearly linked with sexual maturity and reproductive power. It is squeamishness about this that has held the collective conversation about menstruation hostage.

In her book on how menstruation is represented in popular culture, University of Melbourne lecturer Lauren Rosewarne writes that menarche is a crucial moment of gender awareness and segregation. While young children participate in nearly all activities regardless of gender, menarche is the time that separates girls from boys, a division that continues for the rest of their lives.

In separate research not included in her book, Rosewarne talked to many women about their experience of menstruating. One of the recurring themes was the embarrassment the women felt when periods were mentioned in front of family members, particularly males. In that sense, we haven't moved on very much from the women who washed out their menstrual rags and pegged them to a clothesline well away from the menfolk's sensitive eyes (you can bet, though, that men's sweat-stained shirts were not treated with the same sense of shame). Rosewarne is disturbed by the resulting silence about menstruation, which breeds ignorance. In her university classes, for example, she sometimes mentions that women are born with all the eggs they are ever going to have. And often, students are hearing this for the first time. Even Rosewarne, now in her late 30s, acknowledges that she didn't come across this fact herself until she was 22. Why are we failing young people so radically and completely on how their bodies work?

There is this strange, misplaced idea that if adults tell kids about menstruation (that is, before it actually happens), it might strip away their innocence or simply frighten them—the same reasoning is applied to conversations about puberty, as discussed in Chapter 4. But the fact is, as Rosewarne points out, that many girls are still frightened when they reach menarche anyway, because the issue has been handled with such coyness and innate shame. If we spoke about it comfortably from the time children were very young—including talking openly about our own menstrual cycles—it would be far more normalised in terms of everyday life, and cease to be such a source of embarrassment, ignorance and general consternation.

A girl reaching menarche is at a particularly important and sensitive time in her life. Her body is changing and, in the most obvious way possible, she is beginning to shake off the vestiges of childhood and grow into adulthood. Already, she has absorbed many messages about girlhood, womanhood (and manhood, for that matter), sex, sexuality and the female body. The key influences in her life on these issues are her parents and her teachers. In a culture that still treats periods as something a bit giggly and embarrassing and distinctly not to be discussed, girls absorb a sense of shame from an early age. It means they have yet one more thing to feel anxious and insecure about at a time in their lives when anxiety and insecurity can be very high anyway.

How women come to terms with their bodies is an important part of feminism. As females are imbued from the time they are born with the importance of how they look, a girl's sense of her physical self can be a major factor in her self-esteem and her sense of the place she occupies in the world. We also know that puberty is a time when issues around mental health, body image and eating disorders can come to the fore, when young women worry about their sexual attractiveness, often having learnt by osmosis to be harsh critics of themselves. Coming to terms with the physical and emotional changes of puberty is a key way for the transition from girl to woman to be as positive and smooth as possible. And this is particularly important in the context of the new puberty, where girls are experiencing puberty earlier than ever before.

Privacy, secrecy, shame: this is the insidious troika of menstrual history and, sadly, the contemporary experience. Too many girls know too little, too late about puberty, and are left to go through it without any reliable information to draw on.

The American comedienne Tina Fey sums it up well in her recollection of reaching menarche in her memoir _Bossypants. 36_ Having had nothing to go on but a starter kit from Modess (a maker of 'sanitary products') that included the booklets 'Growing Up and Liking It' and 'How Shall I Tell My Daughter?', Fey was in for a major shock when, as a 10-year-old, she found blood in her underpants one day. Her initial response was to ignore it, because 'I knew from commercials that one's menstrual period was a blue liquid that you poured like laundry detergent onto maxi pads to test their absorbency'. But after checking with her mum, she discovered that it was, in fact, her period, and it was—lo and behold—red rather than blue.

'At that moment, two things became clear to me', Fey writes. 'I was now technically a woman, and I would never be a doctor.'
Chapter 8

**Pubertal Problems for Girls**

_I think we are still embarrassed about our bodies. Especially the functions of the female body—periods and public breastfeeding are things to be kept discreet, and not discussed in polite society._

Kelley, 45

EVEN WHEN PUBERTY runs more or less to schedule, it can still be the cause of embarrassment and concern. Imagine, then, how distressing it might be if something unusual seems to be happening on top of all that. Two of the most significant of those issues are precocious puberty and delayed puberty, which are when development occurs unusually early or late, respectively.

As for menstruation, this is a complex process that comes with its own set of potential problems. Among the most common of these for adolescent girls are painful periods, heavy periods, or no periods at all. Then there's endometriosis, adenomyosis and fibroids (the fun never ends with menstruation!), three conditions that are quite common in older women but are pretty much unseen in adolescents just starting on their menstrual journey, mostly because they take years to build up and become problematic. But they are worth knowing about so that young women can be alert to them if symptoms emerge later in their lives—as you'll see, I learnt the value of this the hard way.

We'll take a look at all of these issues in this chapter, as well as the contentious menstrual complaint known as polycystic ovary syndrome.

**Precocious Puberty**

Precocious puberty is defined as when gonadarche, or physical development, occurs before the age of eight in girls and nine in boys. It is about 20 times more common in girls than boys. Given that girls seem to be starting puberty earlier than in previous generations, it may be that a girl is at the early end of the normal scale, rather than experiencing true precocious puberty. It is also the case that while a girl experiences one aspect of development—breasts, for example, or pubic hair—that does not necessarily mean she is about to go through puberty. These developments can occur at a very young age indeed, even in toddlerhood. Whatever a girl's particular situation, it will be assessed by a physician in conjunction with the child and her family—treatment options will be discussed, including no treatment at all.

The main concern with precocious puberty from a physiological perspective is that the child may not reach her full height. This is because she has had a premature growth spurt associated with puberty which has advanced her bone age. A doctor will order an X-ray of her left wrist to determine this bone age, which can indicate the time left for growth and provide a reasonable estimate of how tall she will eventually be. Precocious puberty can reduce the time to the end of the growing period and cause the body's long bones (such as the femur in the thigh) to fuse prematurely. But there are hormonal interventions that can stop puberty and preserve bone growth.

Just as important a consideration for girls with precocious puberty is how it affects their emotional development. It's as if the bodies of these girls, who are very young, suddenly take off without them, and there may not be a correspondingly rapid social and emotional development. This can mean that adults expect more from them because they look older than they are, and it can also make them stand out from their classmates in the most obvious way. This is a lot to cope with when they are emotionally still very much young children, and can cause considerable distress. Again, interventions are possible, though as with everything health-related, it is best to be aware of all the treatment options, and any possible side effects, before making a decision.

A doctor will also check to make sure there is no underlying condition that has caused the hypothalamus to swing into action so early, such as an abnormality of brain development (for example, a tumour or cyst). While it is important to assess the possibility of these abnormalities, it's also important to remember that they are very rare.

**Delayed Puberty**

At the other end of the pubertal spectrum are those kids for whom nothing seems to be happening at all. In both girls and boys, this takes on an interesting sociocultural hue. Puberty is considered late in a girl if there has been no development—no breast buds or pubic hair—by the time she is 12, but also if puberty has begun but the girl has not yet had a period by the time she turns 15. Usually, a girl reaches menarche about 2–3 years after her breasts bud; if the gap is much longer than that, it is worth getting her checked out by a doctor.

The psychological impact of delayed puberty does not seem to be as profound for girls as it is for boys—with so much emphasis on the male physique and its muscularity, boys can be in for a lot of teasing. Girls seem less likely to be subjected to all this, which is perhaps where the myth that delayed puberty does not affect girls comes from. But despite there being perhaps less social pressure for girls around late development, they can still feel left out when their friends are talking about their breasts or periods, and they can be very worried that their development is not normal. It might simply be that late puberty runs in the family—perhaps Mum or Nanna were late bloomers too—and there's nothing to worry about. But again, it is always worth having it checked out in case there's an underlying condition that needs attention. If a specialist does decide that a girl's situation warrants intervention, she can be given oestrogen treatments until her body catches up.

Some underlying conditions can delay puberty in girls. Eating disorders are one of the first things a doctor will assess in an adolescent girl with delayed puberty. Another possibility is that the brain has not yet started to produce follicle-stimulating hormone (FSH) and luteinising hormone (LH), which warrants further examination. It is also possible that there is a problem with the ovaries, which may not be responding to the puberty hormones as they should by producing higher levels of oestrogen. One of the major causes of this is Turner syndrome, a chromosomal disorder in which females are missing all or part of the usual XX chromosomal pattern. It is thought to affect about one in 2000 girls born in Australia.

Girls with Turner syndrome are usually short and infertile, because the eggs in their ovaries die prematurely. Dr Phil Bergman from Monash Health says that while the syndrome is often diagnosed in early childhood, it is sometimes not explored or diagnosed until a girl reaches puberty. Girls with Turner syndrome usually will not go through puberty on their own because they do not ovulate, and will need to be given hormone treatment to do so.

**Amenorrhoea (No Periods)**

Amenorrhoea, which is an absence of menstruation, has two key types: primary and secondary. Primary amenorrhoea is when a girl has never had a period (she has not reached menarche), while secondary amenorrhoea is when a girl has started having periods but they stop for three months in a row if she has regular periods, or six months in a row if she has irregular periods.

It's important to note that irregular periods are very common in adolescent girls, as it takes the body a few years to get into a regular pattern (some never do) and achieve peak fertility. Usually, a girl only starts to ovulate with her periods about a year after menstrual bleeding starts, and again it can be patchy for the first few years, with anovulatory cycles (where no egg is released) being quite common and perfectly normal.

But there are also a number of conditions that can mean a girl may have primary amenorrhoea, some of which are easier to fix that others. When a girl has a period, she bleeds through the fallopian tubes and the hymen. In most girls, there is a hole in the hymen that allows the blood through, but some girls have an imperforated hymen, which means the blood gets trapped in the vagina. Girls with this condition also present with abdominal pain due to the uterus lining's inability to escape. Paediatric gynaecologist Dr Charlotte Elder says that this issue can be rectified with a simple operation that restores the usual function of a hymen—in some ways, it's like releasing a plug and letting out the menstrual blood. Once a girl has had the procedure, her menstrual cycle should return to normal and, unless there's something else going on, that should be the end of the matter.

One of the most obvious causes of secondary amenorrhoea is pregnancy, so that should be investigated if it is a possibility. Another key reason for primary or secondary amenorrhoea may be an eating disorder, trauma or high levels of stress. Elder explains that the hypothalamus, which controls the distribution of gonadotropin-releasing hormones (GnRH) to the pituitary gland, is particularly sensitive to changes in weight or stress levels. The pituitary needs to receive the GnRH in pulses for it to be an effective trigger, and it is this pulsatile action that seems to be affected by things such as dramatic weight loss, excessive exercise and stress. So the pituitary stops sending out increased LH and FSH, which in turn means the ovaries are not pumping out oestrogen. The result: no period.

Elder says it is quite common for some adolescent girls to regularly skip periods at times of high stress (during exams, for example), after which normal function resumes. This is nothing to worry about. But if a girl with a regular cycle misses three consecutive periods, she needs to be examined by a doctor. Obviously if there is an eating disorder underlying the amenorrhoea, that will also need to be treated.

It is also important for girls who are sexually active to know that the absence of a period does not necessarily mean they are infertile, just as the presence of a period does not necessarily mean they are fertile. Phil Bergman tells me that while it is unusual, he has seen young women who do not have periods discover that they are pregnant. So contraception is always advisable for girls and boys who are sexually active, to reduce the risk of sexually transmitted infections as well as unplanned pregnancy.

**Dysmenorrhoea (Painful Periods)**

Many women experience menstrual pain or cramping at some stage of their lives. Painful periods are relatively common in adolescent girls—a US gynaecology textbook says that about 15 per cent of young women have pain that they describe as severe. It is natural to expect some discomfort with menstruation, particularly during the first two days, which are usually the heaviest and so involve the biggest uterine contractions. But pain that interferes with a girl's life, causing her to miss school or sport, or generally makes her miserable, warrants assessment by a doctor. The reproductive system is a particularly sensitive part of the body, and pain can feel acute—it's quite common for period pain to make women feel nauseated or faint, for example.

As with amenorrhoea, dysmenorrhoea can be either a primary or secondary condition. In the primary type, it is menstruation itself that is causing the severe pain; in the secondary type, there is an underlying condition that's causing the pain, such as endometriosis, polyps or fibroids (discussed later in this chapter). Once again, it's the prostaglandins that are implicated in the pain, with some women having higher levels of these important but tricky hormones that are responsible for the uterus contracting during menstruation. The pain can sometimes start before a girl's period even begins, and can bring with it headaches, lower back pain, nausea, diarrhoea or constipation, dizziness or fainting, and fatigue. In short, it can make you feel completely miserable.

The good news is that there are effective treatments, both hormonal and non-hormonal. The first thing that needs to be checked is whether there is another medical problem causing the dysmenorrhoea, in which case that will need to be treated. If it is found to be primary dysmenorrhoea, the contraceptive pill can control severe pain, and a non-steroidal or other anti-inflammatory can effectively inhibit the prostaglandins. There is no need to be anxious about an adolescent girl taking the pill. It is a short-acting medication that will not have any implications for her future fertility—the effects of it end as soon as she stops taking it. And, as with regular period pain, keeping fit, applying a heat pack to the lower abdomen, and bed rest can also help to reduce discomfort.

In general terms, period pain eases as women get older, because the hormone levels for menstruation are lower than in younger women. Many women also find that having a baby changes their menstrual cycle and reduces period pain.

To some extent, menstrual discomfort is part of being a woman, so the key for a young woman is to find an effective way to manage it that will not interfere too much with her life. Having said that, women's legendary stoicism can lead us to suffer in silence, which is entirely unnecessary and psychologically unhealthy. If a girl is being made miserable every month by pain or secondary symptoms, and the above solutions do not work, she needs to have herself checked out and get help in managing her pain.

**Menorrhagia (Heavy Periods)**

Another of the more common menstrual problems in adolescent girls is excessive bleeding. This is defined as a period that lasts longer than seven days, or during which the volume of blood loss is so heavy that it requires a change of tampon or pad more often than every two hours.

Again, heavy bleeding should be investigated to see if there is something else causing it, such as the blood condition called Von Willebrand disorder—people with this condition have a problem with a protein in their blood that causes clotting. It can also be caused by weight changes, stress, infection, chronic disease or hormonal disorders. Gynaecological conditions that can cause heavy bleeding in older women—polyps or fibroids, for example—are extremely rare in adolescents, however, and so are unlikely to be the cause.

Heavy bleeding can, for obvious reasons, cause girls a great deal of distress. Not only does chronic menorrhagia put them at risk of anaemia, it carries obvious practical problems: girls constantly having to change tampons or pads, being worried about 'leaking', and curtailing their usual activities to prevent causing any embarrassment.

One of the key treatments for menorrhagia, like dysmenorrhoea, is the pill. Charlotte Elder says that, for a girl with heavy periods, the pill is best used continuously so that she goes for a while without periods; that is, she keeps taking the hormonal pills and skips the sugar pills, thereby keeping her period at bay. The benefit of this is that it stops the heavy blood loss and so also stops her iron levels from tanking.

Another option is tranexamic acid, a medication that curbs bleeding and which is taken during a period. An oral progesterone can also help to thin the lining of the uterus so that there is less to expel each month, and oestrogen can help stabilise the bleeding. Anti-inflammatories not only reduce pain but can also significantly reduce blood flow if taken regularly during the first two days of a period.

**Endometriosis, Adenomyosis and Fibroids**

When I was about 19, I fainted at work on the first day of a period. Fortunately, being an experienced fainter—I come from a family of swooners—I knew the warning signs well enough (that horrible feeling like a big, black curtain coming down) to get myself on the ground, and no damage was done. I didn't think anything of it at the time, putting it down to a one-off nasty bout of period pain. But over the next few years it happened again and again, on an intermittent basis. Always it was around the start of my period. Always the pain was terrible for about half an hour, then it would abate. Always I would pass out from the pain—or at least start to pass out until I got myself on the floor and somewhere cool.

Then I was on the pill for many years, the pain went away, and I thought little more of it. But as I moved into my mid-30s, I started to have occasional bouts of this pain again, usually in the middle of the night, always relatively brief but agonising, with me writhing on the bathroom floor, my body breaking out in a huge sweat as my brain fought to not lose consciousness from the pain. I had it investigated several times, but nothing noteworthy was found: the ultrasounds and pelvic examinations were clear. So, like a lot of women, I just pressed on, accepting this as part of my menstrual cycle and focusing on combatting it. In truth, though, I didn't even know if that's what it was: these episodes were happening further and further away from the start of my period, even mid-cycle.

I started to dread being woken up by it in the middle of the night. I kept an emergency supply of anti-inflammatories in the bathroom cupboard, along with UHT milk to take them with so that I didn't vomit them straight back up. The episodes became more and more frequent, more agonisingly painful and more distressing—for the rest of the day on which they happened, I'd feel like I'd been hit by a truck. I googled and googled, trying to find a diagnosis that matched my symptoms. The closest thing to it was endometriosis, but my situation did not match that condition's typical symptoms. Again I dismissed it and simply hoped it wasn't something that would impede my fertility, that it would instead just magically disappear.

In my late 30s, after several unsuccessful rounds of IVF, my mind kept returning to this problem. My lack of success was on my lovely fertility doctor's mind too, so he referred me to a colleague, Associate Professor Kate Stern, a gynaecologist and obstetrician who is also a fertility specialist. Kate is a straight talker and smart as a whip, and in our first meeting she told me there was no point in proceeding with IVF until she had ordered a full set of blood tests and done a laparoscopy to see if there were any structural problems preventing me from becoming pregnant. I was running out of money and worn out by the constant cycle of anxiety, hopefulness, then crushing disappointment. I knew she was right.

Endometriosis is a common condition that's thought to affect about 10 per cent of women in their reproductive years. It's also a complex and mysterious disease about which there is still relatively little known, such as exactly what causes it. It seems to occur when some of the endometrial tissue that lines the uterus is displaced and grows outside the uterus—in the bowel, the pelvis, on the ovaries, in the fallopian tubes or even in the vagina—and it's usually characterised by severe menstrual pain and heavy bleeding. It can also impede fertility, though it does not necessarily do so, and it is often only when a woman wants to become pregnant that 'endo' becomes a significant problem.

The only sure way to diagnose endometriosis is through a laparoscopy, a minor surgical procedure done under anaesthetic, in which a long, thin telescope with a light attached is inserted through an incision beneath the navel to enable the surgeon to see any endometrial tissue. When Kate did my laparoscopy, she found endometriosis everywhere. (It should be said here that there is no link between the amount of the disease and the amount of pain—some women have a lot of endometriosis and no pain, while others have small amounts of it and a lot of pain.) Kate removed it by ablating the displaced tissue and effectively 'cleaning' the organs.

I still don't know if the endometriosis was causing my strange symptoms. All I can report is that since the surgery, I have not had another episode; in fact, I have had no period pain at all. And on my second IVF cycle after the laparoscopy, I became pregnant.

Kate explains that the link between endometriosis and fertility is a complicated one. As a fertility specialist, she sees a lot of women with endometriosis, and stresses that in 90 per cent of cases the condition is mild and has only a small impact on fertility. In the more severe cases, the disease can damage reproductive organs by causing scar tissue on, for example, the fallopian tubes or the ovaries. In milder cases, though, the impact is much subtler, affecting fertility at the cellular level and having some deleterious effects on egg quality and implantation. And while it can be a distressing condition, it can also be treated, either surgically or hormonally.

The reason I am recounting my own experience here is that it taught me an important lesson about my body, and about taking control of it. Pain on the level that I was experiencing is not normal. Why on earth did I put up with it for as long as I did? Writhing in agony on the bathroom floor at 2 a.m. is the body's not-so-subtle way of saying something is up. Even though I couldn't get a diagnosis for what I had, I should have insisted that it be explored further, because something was obviously wrong.

While endometriosis is uncommon in adolescents, it can occur, and this is worth bearing in mind if a girl is experiencing severe menstrual pain. A related yet distinct condition is adenomyosis, in which the uterus lining makes its way into the muscle wall. Often, women who have adenomyosis will also have endometriosis, as it has the same underlying problem—the endometrial tissue is ending up where it shouldn't. It also has similar symptoms to endometriosis: heavy or painful periods, bleeding between periods, pain during sex, fatigue and dizziness.

Again, adenomyosis is extremely rare in adolescents, as it usually builds up after several years of increased oestrogen levels. In fact, it is most common in women who have had babies, particularly those who have had surgery to the uterus (for example, a caesarean section). Often, adenomyosis and endometriosis are resolved by menopause, when oestrogen levels drop. However, there are obviously a lot of years of pain involved in the meantime, so the various available treatment options, both hormonal and surgical, should be considered. The adenomyoma can be removed through a laparoscopy or with ultrasound. For some women, the condition will be so severe that they may opt for a hysterectomy.

Fibroids are also unusual in young women, but they become more common as the reproductive years roll on. These are lumps of muscle tissue that attach to the wall of the uterus, causing heavy bleeding and severe pain. They can be tiny or as big as a melon, sometimes causing pain if the abdomen is pressed because they are so large. They can impede fertility, not to mention seriously impact on a woman's quality of life, and again there are hormonal and surgical treatment options, which will need to be assessed according to a woman's symptoms and her stage of life.

**Polycystic Ovary Syndrome (PCOS)**

Of all the menstrual complaints that can afflict adolescent girls, polycystic ovary syndrome is probably the most hotly debated within medicine. Part of the contestation is around diagnosis, because ovarian cysts and irregular periods—key symptoms of PCOS—are very common in adolescent girls.

Here is the problem: a diagnosis of polycystic ovaries, which are relatively common and not necessarily anything to be concerned about, is quite different from a diagnosis of polycystic ovary _syndrome._ Several doctors I spoke to expressed their concern that the two conditions were confused, and that women were being diagnosed unnecessarily, in turn causing unnecessary worry.

Dr Cecilia Garcia Rudaz, a paediatric endocrinologist at Canberra Hospital and an expert on PCOS in adolescents, says that new guidelines adopted by the Australasian Paediatric Endocrine Group, and accepted around the world, make explicit the following criteria for a PCOS diagnosis: there must be at least moderate hirsutism (excess body hair, particularly on the face or trunk) combined with abnormally high testosterone levels, and abnormal periods persisting more than two years after menarche. Where once the diagnosis involved an analysis of ovarian volume and follicle numbers, that is no longer of primary concern. It is important to note, too, that the diagnostic criteria for PCOS in adolescents are different from those for adult women.

PCOS can be a distressing condition. The excess male hormones can cause hirsutism, loss of hair on the scalp, and acne. And the cysts on the ovaries can impede fertility by interfering with ovulation, preventing the follicles from maturing and producing eggs that can be fertilised.

The relationship between weight and PCOS is a tricky one. Women with genuine PCOS are often overweight and can develop insulin resistance, which means they have higher levels of insulin in their bodies. This in turn can increase the activity of the androgens in their bodies, and places them at higher risk of developing type 2 diabetes. The good news is that lifestyle changes—increasing exercise and losing a little weight—can resolve PCOS or at least minimise its effects, as well as allowing insulin to work more effectively in the body.

However, Kate Stern says the perceived link between PCOS and weight can be a misleading one. She has seen girls of normal weight, and even girls with eating disorders, who present with symptoms matching PCOS, and so are vulnerable to misdiagnosis. Being labelled with the disorder can simply exacerbate the body image issues they already have. Instead, it is crucial that the diagnosis include a blood test to measure a girl's hormone levels, rather than simply relying on the presence of cysts on the ovaries or irregular periods.

What PCOS can do is change a woman's ability to become pregnant (though by no means does it always do so). It can also increase the risk of miscarriage. Stern says it is not the PCOS that increases that risk, but rather excess weight, so again, losing even a small amount of weight can be hugely beneficial.

One of the issues with diagnosing the condition in girls who are still growing, and whose menstrual cycles are still settling into a regular pattern, is that there is no consensus among medical professionals on exactly how to go about this. When, for example, is it just irregular periods in an overweight girl, and when is it PCOS? That's one reason why, Stern says, 'a lot of people believe it shouldn't be diagnosed in adolescents'. Rudaz says that the new diagnostic guidelines, which have been established globally and will soon be presented at an international meeting of paediatric endocrinology, will make it easier for doctors assessing adolescent girls for PCOS to make a more accurate diagnosis and give better treatment options.

Of course, if medical experts are sometimes confused by the diagnosis of PCOS, then most parents have no hope at all. Needless to say, if your daughter is worried about hirsutism, acne, weight gain or irregular periods, these are all worth investigating further. Obviously, anything that causes a young person distress or worry needs to be evaluated by an expert and then treated where necessary, or possible. Some conditions will benefit from treatment, but just know that they may not necessarily have any long-term implications—they may in fact just be part of growing up.

**Helping Girls to Be Comfortable with Their Bodies**

While all the aforementioned issues are problems that can accompany puberty, for most young people there will be little physiological grief beyond the changes associated with normal pubertal development. But if a girl does experience issues with early or delayed puberty, or problems associated with her period, it's important that she is able to seek help without feeling embarrassed.

That's where we, as parents, come in, not just when our kids reach puberty but right from the start—talking openly, frankly and in an age-appropriate way about their bodies and the changes they will undergo as they grow up. And of course, there's that delicate line to tread in respecting their privacy, too, and realising that part of adolescence is children establishing themselves as independent of their families. Sometimes it's enough to just be there, ready to talk. Self-esteem is a precarious prospect in adolescence in any case—it's unnecessarily corrosive to have kids feeling further shame and embarrassment about their bodies and development.

The physiological problems associated with puberty are, in many ways, the easiest ones to diagnose: the ones that show themselves in an ultrasound or a blood test. Much harder and more insidious are issues that affect young people's emotional and psychological wellbeing as they go through puberty. For girls in particular, this can mean sudden attention (welcome or unwelcome) about how they look, their weight, their shape, their 'womanliness'. Many parents of daughters worry that earlier puberty and the increasingly sexualised world in which we live, combined with the potency of social media and technology, will lead to girls being sexualised before they are ready, and before they want to be. Add aggressive, gender-based marketing to pre-pubertal and pubertal girls at a time in their social lives when relationships are tested and reformed, and you have a heady combination indeed.
Chapter 9

**'Don't You Look Pretty?'**

Body Image, Sexualisation and Mental Health in Pubertal Girls

_I don't want my daughter to grow up too fast, be taken advantage of, or feel pressured to do anything she doesn't want to do. Younger puberty means a child may look older but emotionally and mentally still be 11. Scary!_

Joanna, 34

THE 'DON'T YOU look pretty?' line may seem innocuous enough, and in some ways, it is. The intention is almost always to make a girl feel good about herself. Trouble is, it also reinforces the idea that what's most valuable about her is the way she looks, and that prettiness is a powerful currency, a view corroborated by a culture far too concerned with appearance and particularly with female attractiveness.

It hits girls particularly hard. We rarely say to boys: 'Don't you look handsome?' We don't often notice what they're wearing at all, and they do not grow up as concerned about their physical appearance as girls. This is all reinforced by a culture that still gazes at the female form differently from the way it gazes at the male, and imposes strict ideals of attractiveness. Ironically, there is greater cultural freedom in the idea of what is _female_ —a girl wearing jeans, a hoodie and short hair would barely raise an eyebrow, whereas a boy in a fairy dress would be a different matter. But that has more to do with the restrictiveness of gender roles than with body image.

I can hear you saying that boys are subjected to pressure—subtle and unsubtle—on body image too. This is true. There's a great deal of money to be made at the intersection of personal appearance and human insecurity, so there is no reason to exclude half the population from it: aftershaves (Or wait, are they 'scents' now?), hair removal, hair sculpting, muscle building, teeth whitening and tanning are becoming increasingly popular with men. Even the little fellows at my daughter's child care have their hair artfully arranged into an upstanding wave design. God knows how much hair product those lads from One Direction go through each month, but every one of them has a living piece of installation art on his head.

Yet, despite this, it is girls who grow up with far more attention paid to the way they look, which they absorb and use to self-critique, sometimes with devastating consequences. That's certainly the view of Dr Elise Holland, an academic at the University of Melbourne with a particular interest in body image. She says there is no question that girls are more profoundly affected by body image issues than boys.

A 2014 Australian study found that even very young girls—of primary-school age—have absorbed cultural messages about female attractiveness and have begun to critique their own bodies accordingly. Sadly, we've all heard it before: 'I'm too fat.' 'I have big thighs.' 'My friend is prettier than me.' 'My ears stick out.' On and on it goes, into adolescence and, in many cases, through to adulthood and parenting. Some of us never really shake it off, no matter how much we understand it at an intellectual level—it embeds itself at an emotional level, cunningly making its way around rationality. The Australian study also found that young girls aged 6–11 years—so in many cases still pre-pubertal—reported levels of self-objectification that were similar to those of adult women (and much more pronounced than for boys).That is, they had unwittingly absorbed distorted cultural messages about gender, appearance and body size so effectively that they were critiquing their own bodies in the same way as adult women. This, in turn, was linked to body image problems and eating disorders in the children.

The idealisation of certain body types that children absorb through pop culture is a well-worn but nonetheless potent matter of concern on which we never seem to make much headway. The depiction of women in magazines and films, on television and the internet, continues to present what for most people is an unattainable ideal of beauty. And newcomers are adding to the carnival mirrors of body image, a good example being the 'fitspiration' or 'fitspo' movement on social media. This presents idealised images of extremely ripped, trim, lycra-clad women, often glistening with beads of inspirational sweat and accompanied by motivational slogans. The movement has proto-feminist claims in presenting women as fit and strong—one of its catchcries is 'Strong is the new skinny'—but nonetheless it still presents a goal that is unattainable by most women.

There is also an ugly reality to contend with: the world is still not an equal place for females. Even though they generally outperform boys at school and outnumber them at university, girls can still look forward to unequal pay, they carry a far greater share of the housework and child-rearing burden, they are far more likely to be victims of family violence, and—perhaps most significantly of all—they do not expect to tread as smooth a path through life as boys. This remains the context in which we are raising our children and against which we must push, questioning our own assumptions and impulses.

The 'Don't you look pretty' syndrome is so deeply ingrained in us that as parents it can take us by surprise, even those of us who work hard at teaching our kids that they are so much more than what they look like. I have had to think long and hard about this regarding my daughter. How often have I found myself browsing for clothing for her, thinking about how gorgeous she'd look in this or that, when the hard truth is that, as a three-year-old, she's not in the least bit interested in her clothing: when I buy her certain clothes, I buy them for me. I buy them because I like seeing her in them, and even though I am not very interested in fashion myself, and am keen for my daughter to not become materialistic and vain, I nonetheless get a visceral pleasure from buying things for her—too many things. Put it down to some weird confusion of love, but it still all feeds into the issue about girls and their appearances.

So the question is: How do we stop ourselves from passing on our own neuroses and, in the modern parlance, general _issues_ about body image, which many of us know from bitter experience can cause profound anxiety, self-loathing and unhappiness? This is a difficult question, but one we must make ourselves answer as we guide our children to adulthood. No-one, for instance, wants their child to be overweight—we are all aware of the physical, emotional and social difficulties that come with that, in childhood and in adulthood. But neither do we want our kids to be constantly worrying about their size and shape, feeling insecure or anxious about it, prone to bouncing from one unhealthy fad diet to another or, in extreme circumstances, developing an eating disorder. Walking that fine line is a real challenge, and before we can meet it, we first need to do some hard work on ourselves—although this is particularly complicated for women, for the reasons already mentioned.

I can remember the searing shame I felt as a kid when someone made a comment about my body: my solid legs, my big feet, my chunky eyebrows, my bad skin. I still have all those things today, but I've found a way to, quite frankly, not give a shit about them—except the eyebrows, which I wax, lest they start to grow tropical fruit or devour small children. This is one of the blessings of middle age, but it's been a long, hard road to get here, and I certainly want to help make it an easier one for my daughter.

One priority is to look at our own relationship with food—most of us have at least some bad habits, often tied to our emotional state—and think about how, or if, we want to pass that on to our children. One of the refrains of my own childhood was that someone was 'on a diet', or I'd be asked if I was 'on a diet'. Often I was, usually at great emotional expense, and with few health benefits. When I was in Year 7, a ballet teacher took to weighing me in her office every Monday after school. She told me at our first weigh-in that I was as heavy as a much older girl who was the star of the ballet school, which made me feel deeply ashamed. I came to dread those Monday appointments. I wouldn't eat all day at school, worrying about what the teacher would think if I hadn't lost weight, desperate for her approval. In truth, I was nearly starving myself, so of course the 'diet' didn't last. And in the meantime, it made a big dent in my self-esteem.

Most diet experts and medical professionals will tell you that a diet as such—a thorough change in eating habits that radically reduces kilojoule intake—doesn't work. Anything that feels like suffering is likely to be temporary, and people often quickly revert to their old habits, regaining any lost weight and even adding on more. What works—and of course, this is far easier said than done—are those old, simple-yet-difficult behaviours: eat better, exercise more.

I say all of this as someone whose weight has yo-yoed dramatically over the years. I still struggle. I hate trying on clothes, despairing that nothing looks good on me, which is why I rarely shop for myself. I was delighted when my daughter graduated from her toddler swimming classes, because it meant I no longer had to stuff myself into my bathers and get into the pool with her. At the same time, I try very hard not to make any negative comments about my weight to my daughter, and I talk to her about food in terms of her health and not her appearance (she's not a big kid, so hopefully she'll have a natural advantage in all of this as she grows up). As I have said, these issues are difficult: while we may understand them on an intellectual level, getting an emotional grip on them is an altogether different, and more difficult, proposition. But if we're ever going to get out of this body image trap, and help young women avoid it, we must keep trying—and that goes for men as well as women.

Reaching puberty is something of a crucible for body image: bodies change and become 'adult' in appearance, most conspicuously those of girls. Boobs emerge, hips become rounder, and hormones kick in. It's perfectly understandable for parents who notice these changes to worry about them: How will this transition be for my daughter? How will it change her, beyond the most obvious way? The sexualisation of girls is a highly complex area, worth a book in its own right. For now, though, I'm interested in how it intersects with body image and puberty. It certainly causes a lot of people a great deal of concern, not just in regard to girls but boys as well: so much so, in fact, that in 2008 the Rudd government commissioned a Senate inquiry into the sexualisation of children in the media.

The first recommendation the inquiry committee made began in the following way: 'The committee considers that the inappropriate sexualisation of children in Australia is of increasing concern'. It then went on to recommend a number of mostly bureaucratic measures to better manage the images children have access to, including stricter controls around sexually explicit material and more rigorous classification systems. Importantly, the final recommendation was for the 'introduction into all Australian schools of comprehensive sexual health and relationships education programs... adopting a consistent national approach to the question'. I will address this issue in more detail in Part IV, but again, while this seems to be the most logical and effective approach in addressing these concerns, it never gets off the ground.

Body image and sexualisation, of course, are not the same thing, but they do have a certain nexus. Body image is the relationship that we have with—including the opinion we have of—our corporeal selves. I don't know many women, no matter how intelligent, thoughtful, strong or independent-minded, who don't have at least some level of discontent with their bodies. We all readily point out the bits that we don't like, or that we think are faulty: the big bum, the flat chest, the pointy nose, the soft stomach. It tends to ease as we get older, but it never really goes away, and for young women it can be pervasive and deeply psychologically damaging. We are trained in this ability to critique ourselves, often harshly, from birth, surrounded by images and ideals of (for most of us) an unattainable and narrow attractiveness. And during adolescence, the ability to notice, observe, compare and assess is ramped up dramatically.

When we talk of the sexualisation of young girls, this includes the way in which girls are taught, through the cultural environment, how to market themselves sexually and make sure they nab a man—and yes, it's still men they are trained to impress. This can mean acting in a 'sexual' way, often assumed to be absorbed via popular culture (big shout-out to Lady Gaga, Miley Cyrus and all the rest). In children, there is an assumption that this involves the innocent copying of other behaviour, a sort of 'monkey see, monkey do' effect, that catapults them into the adult world long before they are ready, potentially frightening them (or others), or causing psychological harm. It seems to crop up most often in the form of the social media storms created by large department stores selling clothes deemed to be 'inappropriate': retailers are much more sensitive to this now, often pulling items from sale at the slightest hint of online trouble. But high-profile cultural figures, such as pop singers, are often blamed too.

There are a couple of problems with this. Firstly, a girl's sexuality is not something she receives for her birthday one year, or picks up at the Boxing Day sales. It's there from birth. You only need look at how instinctively babies and toddlers play with their genitals—they do that because it feels good. We still have a lot of trouble dealing with this fact; somehow, we are afraid of children's sexuality in general. Regardless, while it may be that young girls are exposed to sexualised culture earlier than they need to be, and before they can understand it, they are not always the mindless cultural dupes they are often assumed to be in this debate. They do not necessarily adopt these behaviours from a point of weakness—they may simply be expressing their identity and experimenting a bit.

Often these concerns centre on girls' clothing. Now if you think certain clothes are inappropriate for your young daughter, then obviously you can choose to not buy them. Retailers will soon get the message, and in lots of ways I think they already have. A recent storm of parental protest on social media about a 'sexist' T-shirt for girls sold by a large department store saw the item quickly withdrawn. If, at a later age, a young woman wants to wear sexy clothing, then clearly she ought to be able to without judgements being made about her character. What she is wearing simply shouldn't be an issue for anyone but her—if she fancies showing off her boobs, then more power to her.

Having said that, we all know that parental control over these things only extends so far, and kids are adept at adapting their clothes to match a particular style that they admire or think is cool. The older they are, the more you may have to negotiate on this. Younger children can quite innocently wear clothes in a way that is perceived by others as 'inappropriate' or 'sexual'. The navigation of this with girls starts from the time they are toddlers and insist on lifting their dresses in public to show their underpants to all and sundry. It's one of those situations where, as parents, we have to decide where we think the line is and then enforce it as best we can.

One of the problems with talking about sexualisation and girls is that it's such an enormous topic, and the research evidence on it is so limited. But we all know the insidious forces at play. Too often girls get locked into that age-old dichotomy: virgin or whore; frigid or slutty. The pressure on them to look and act a certain way is immense, and the retribution—often by other girls—can be swift and sharp if they don't conform. Tina Fey's 2004 film _Mean Girls_ is still one of the sharpest and best explorations of this, worth tracking down if you haven't seen it.

Body image is intrinsically tied up with all of this and, again, it doesn't magically make an appearance at adolescence. It is brewing away in girls from the time they are born—the rapid brain development of adolescence, the hormonal surge and changing social circumstances (growing up, gaining independence, figuring out who they are) simply intensifies and complicates it. And this can reach the point where severe health problems can develop.

One of the cultural issues that has changed a lot since I was a child involves the complex messages we now receive about food, weight and diet. We know that we are in the grip of an obesity epidemic, and understand the serious consequences that will have for our collective health, not to mention the significant cost to the public purse. We are constantly being advised—often through the use of contradictory 'facts'—about which diet is the best and healthiest: low carb, low fat, high carb, high protein, 5 and 2 diet, lemon detox... What the hell is freekeh and how do I cook it anyway? Health experts are careful not to induce shame by using the words 'fat' or 'obese', opting instead for 'above their most healthy weight' or some other euphemism, but we all know what they mean. At the same time, we live in a culture drenched in food porn. Chefs are celebrities; reality TV shows are centred on the relationship between cooking, love and hardship; and high-fat, high-sugar foods are cheap and easily accessible. If adults can't make sense of all this, how on earth can children and adolescents?

One of the most serious consequences of this body image confusion is the development of eating disorders. While the prevalence of anorexia nervosa—the disorder with the highest mortality rate—has plateaued in recent years, there has been an increase in its prevalence among teenage girls. Another disorder, bulimia nervosa—compulsive eating followed by induced vomiting—continues to be a problem too, even though its prevalence seems to have tapered off since the 1990s.

As director of the Centre for Adolescent Health at Melbourne's Royal Children's Hospital, Professor Susan Sawyer spends much of her professional life talking, thinking and reading about, not to mention treating, eating disorders. She says there is no question that doctors are seeing younger and younger children who are suffering from anorexia, and that even though there are certainly boys who have anorexia, it remains far more common among girls. It is no longer unusual, Sawyer says, for a girl of 11 or 12 to be treated for the disorder.

Sawyer says that, beyond the genetic contribution to anorexia nervosa, experts are not entirely sure why this is so, but her view is that there are three key factors here. The first is higher rates of anxiety in children and adolescents more generally, triggered by unstable families, school pressure, overcommitment of time and the omnipresence of social media. These have led to a truncation of childhood—in her words, 'The heat's being turned up at a younger age'.

Secondly, children have access to far more explicit images of the 'body beautiful' that are often highly sexualised. This is replicated in the selfies that kids take that need to be just _so_ to garner the number of 'likes' that make it all worthwhile (and potentially devastating if those likes and LOLs and comments like 'ur hot, babe!' are not forthcoming). For girls, this often means replicating the 'duck lips' pictures that are so widespread on social media, aimed at making them look as adorbs as possible.

Finally, as I mentioned earlier, there are the confusing messages being received about obesity and weight. Children are particularly vulnerable to absorbing the message that fat is bad, and taking dramatic steps to redress it.

All of this plays out in heart-rending fashion among young people who are diagnosed with atypical anorexia. This is when a young person starts out overweight or even obese, but then loses weight so dramatically and quickly that they develop some of the same health problems linked to anorexia nervosa (such as strain on organ function), even if they are not technically underweight or are even still overweight. Sawyer says these young people are often in even worse health than those with the more typical anorexia, such is the stress on their bodies and minds.

Sawyer also thinks that the increasing sexualisation of girls in particular (but not just girls) is a real concern. She has noticed how it has manifested in the young people she has treated over the years: the increasing attention to fashion, the hair-dos, the make-up, the perfect manicures. Childhood seems to be changing so quickly, she says, whereas she strongly feels that children 'ought to be allowed to be children'.

One of the other risks for girls around the time of puberty is the onset of anxiety and depression. Professor George Patton, an adolescent psychiatrist at the Royal Children's Hospital, has looked closely at the relationship between pubertal stage and depressive symptoms in adolescent girls. He has found that there is a distinct correlation: in other words, there is likely a link between rising oestrogen levels and the onset of depression. More specifically, he says, there is likely a complex interaction between biology and social circumstances.

This does not mean there is necessarily cause for alarm. It is quite common for girls to experience depressive symptoms in adolescence and then to 'grow out' of them into adulthood. While adult depression often shows itself in the teenage years, it is not the case that a teenager with depression will always end up an adult with depression—the relationship is strong in one direction, but not in the other. Patton stresses that the link between pubertal development and depression is still in the early stages in research terms, and much more needs to be known about it.

One of the challenges of adolescence—though, of course, it is also one of the delights of adolescence—is a young person's burgeoning sexuality. Girls may masturbate more than they did (or for the first time), have sexual fantasies, become interested in dating, experiment sexually and eventually have sex. This can also be a time when young people realise that their sexuality is different from that of their friends, that they may be gay or bisexual, or even question their gender (though this often occurs before puberty). Some kids will be completely comfortable and confident in 'coming out', aided by a supportive family and school environment. Others will not, and the stress associated with this can be overwhelming. Some will also have to contend with a religious or cultural background that makes coming out even more difficult, worrying about how it might change their relationships with their parents, siblings and friends.

LGBTI young people are still too often victims of bullying and harassment, and the rise of social media has only made this more difficult to navigate. The mental health advocacy group beyondblue says that 36 per cent of transgender Australians and 24 per cent of gay, lesbian and bisexual Australians have had a depressive episode, compared with 7 per cent of the general population. Same-sex-attracted young people are six times more likely to attempt suicide than their heterosexual peers, and the average age of the first attempt is 16—often just before they come out. While many of us like to think that being gay or bisexual is much more accepted now than it once was, it is nonetheless true that a stigma remains, and young people feel this very keenly.

Psychologist Dr Michael Carr-Gregg specialises in the mental health of children and adolescents. He says there are some key ways in which parents can support their kids in coming out:

• Show love, kindness and appreciation for their honesty.

• Tell them you know how tough it can be to talk about something deeply personal, potentially at great risk to themselves. Bring up the fact that your child might be scared of losing your love and support, and reassure them.

• Recognise that their homosexuality is not a rejection of your values or lifestyle.

• Being gay is not a choice. Tell them you intend to help them to make the most of who they are.

• Don't assume that because your child is young, they don't know themselves or their sexuality. While many people have same-sex experiences but go on to form heterosexual relationships, many also report knowing from a very young age that they were gay.

• Take their coming out seriously. You likely wouldn't challenge a child who was expressing heterosexual preferences, no matter how young.

• Be kind to yourself. It can be a big surprise to discover that your child is gay. It's OK to feel hurt or helpless, to worry. This is a time of change for you too. Talk to a psychologist, or a friend.

• Remember that your child has not changed. The only difference is that they've been more honest with you than they've probably ever been.

• You haven't failed as a parent because your child is gay, nor did you make your child gay somehow. Nothing you did or didn't do during the life of your child has made them gay, just like nothing a parent does makes their child heterosexual.

Carr-Gregg also has been alarmed by what he sees as a push for children to grow up long before they're ready. This is not a new concern, it must be said—for some time now, parents have been worried about the truncation of childhood, mostly through the endless powerful tools of popular culture. But Carr-Gregg says that he is seeing more anxiety and depression in adolescents now than at any other time in his 30 years of practice. In fact, a recent federal government report says that about one in seven Australian children aged 4–17 has a mental health problem (this includes attention deficit hyperactivity disorder, or ADHD; anxiety; depression; and conduct disorders).

Young people's capacity to manage their own wellbeing, their sleep (they don't have anywhere near enough) and their diet (it's very unhealthy) is at an all-time low, says Carr-Gregg. And while an excess of 'screen time'—an overdependence on phones, tablets and other screens—is often fingered as the key problem facing young people, Carr-Gregg believes that is a minor concern next to low self-esteem and impulse-control problems. He believes that social media can actually have a very positive impact on young people and their sense of connectedness, providing they have strong 'digital citizenship' skills and know how to keep themselves safe online.

The truth is that even if a girl does not have a mental health problem—and most don't—puberty can still be a difficult emotional and psychological transition. One of the things parents often mention, with no small degree of sadness, is the time when that pre-pubertal child who was so loving and open and happy suddenly became sullen, secretive and uncommunicative. Parents can feel like they are being shut out, and begin worrying that this is because their child is harbouring some terrible secret or unhappiness, or that their child loves them less than she used to. Then there's the contempt that teenage girls can specialise in: the eye roll, the heavy sigh, the inference that you don't know anything, the passive aggression, the unwillingness to listen or treat you with respect, the door slamming.

But as challenging as this behaviour is, as much as it might make parents want to tear their hair out, it's all very normal too. Adolescents are trying to establish themselves, slowly, as young adults, and that necessarily means withdrawing from the family in some respect. It doesn't have to mean they are unhappy or depressed. (And they do tend to grow out of it—most of us will remember doing at least some of that to our own parents when we were teenagers.)

Carr-Gregg says that adolescents ask themselves three big questions: Who am I? Am I normal? Where am I going? To answer these, they have to establish themselves as individuals, separate from their parents. So the sense that a lot of parents have at this time of their daughter withdrawing and becoming uncommunicative is entirely normal, albeit frustrating.

That said, there are certainly young people who have issues that are not normal, and they will need help. Carr-Gregg suggests asking yourself these four questions to assess if your child needs such help:

1. Do they have the capacity to obtain, maintain and retain friendships? A rich supply of friends, based on quality rather than quantity, is one of the keys to good mental health.

2. Do they refuse to participate in social situations, such as parties, family gatherings or sleepovers? If they are anxious about these activities, they may need some help.

3. Are they having similar problems at school?

4. Do they have 'islands of competence'? By this, Carr-Gregg is talking about your children having a particular passion, something that gets them out of bed in the morning. He says that when he sees a kid with 'no spark', that's when he starts to worry.

Where does all of this leave us? The shift that we are seeing in pubertal girls is twofold: there is biological advancement at the onset of puberty, and it is happening in a culture that is becoming increasingly sexualised and in which children have ready access to adult images and ideas. But what is not necessarily happening is a concomitant rise in emotional and social maturity that would help them to cope with this, not just in terms of their own development but that of their friends and peers as well.

No-one wants their children to be robbed of their childhood. Oscar Wilde famously observed that youth is wasted on the young, and he was spot on: it's probably only in adulthood that we truly understand how wonderful childhood can be, and become determined to let our own children enjoy it before the responsibilities and anxieties—in addition to the joys and the freedoms—of adulthood set in.

But there is no winding back the clock on this. There is no holding pop culture at bay, erasing technological advances or destroying the iPhone. They are as wonderful, entertaining and liberating as they are dangerous and damaging. What we need to do instead is develop countering strategies, and the only two that make any sense are education (this includes adults and children) and active engagement.

What I mean by 'education' here is teaching girls and boys, from the time they are babies, that their appearance is not what matters, that they are far more than how they look. It's about building self-esteem and resilience. This includes, as much as possible, keeping a handle on our own neuroses and insecurities about the way we look, and that means first being honest with ourselves about how they affect us, and the ways in which they might manifest in our parenting. We won't succeed in this all the time—sometimes we won't even realise we've messed up until long after it's done—but we can present a counter-narrative. 'You are smart.' 'You are brave.' 'You are kind.' 'You make me laugh' (a personal favourite). Then, the occasional 'Don't you look pretty' won't have so much potency.

Early, consistent and age-appropriate sexuality education is vital too, as discussed in Chapter 4. We need to start talking to children from early primary school onwards about their bodies—without embarrassment, fear or concern that being informed will somehow make them sexually precocious (which is nonsense).

Toys and clothing are a market, like everything else, which is undergirded by economic rather than social principles. The goods marketed to children (and that means to parents) are heavily gendered, because gender sells. If we don't buy the dolls with the short skirts or the make-up for preschoolers or the clippy-cloppy shoes and make-up for four-year-olds, then the market dwindles and manufacturers come up with something else. That is active parenting, active engagement. Again, I know very well that this is not always easy. Few things are as hard to resist as a pleading, pestering (albeit adorable) child, so we won't always get there. But if we try, then we will slowly make a difference.

We cannot keep being afraid of this, because too much damage is being done. We are the only ones who can change things, and we need to start doing so right now.
III

Boys and Puberty
Chapter 10

**What's Happening to Me?**

_When I had my first wet dream at night—I was 11, I think—and was reaching for the light switch to see what the heck had just happened, I reminded myself not to panic if I saw blood everywhere when the light came on. I'd once seen a bull with blood on its cock in a paddock, and my cousin had sagely informed me at the time that it was sperm. I assumed that human sperm might look like blood too. So maybe I hadn't read_ Where Did I Come From? _as carefully as I should have._

Tom, 45

_I remember being pretty uncomfortable about the way many of my friends were more manly and hairy than I was. I wanted to catch up, but things moved slowly, or it felt slowly anyway. I wanted to have hair on my face and have to shave, but my cheeks and chin were pretty bare for what seemed like a long time... it caused me quite a lot of anxiety._

Jason, 45

I AM ON THE phone to an old friend, asking him what he remembers about his own puberty. Was it difficult, easy, embarrassing? Did he have enough good information? He pauses and thinks for a while. 'What I remember most', he says drily, 'was just how constant the erections were'. He says that he and his mate used to refer to an erection as the 'inexplicable'—their code word for what prompted them to artfully arrange a textbook on their lap and stick a hand in their trouser pocket to frantically press down the wayward penis. There was usually no trigger for the erections—hence, 'inexplicable'—which was the most mortifying thing of all. 'You'd just be sitting there', my friend says, 'conjugating French verbs, when suddenly...'

Did he and his mate have a technique for dealing with the 'inexplicable'? 'Well, you might give it a good whack with a ruler', he replied. To my uproarious laughter—I have a vision of a penis rearing up in response, like a cobra about to strike—he adds that there was a story going around his school at the time that nurses used to deal with spontaneous erections in male patients by slapping them down with a spoon.

What this meant, of course, was that my friend, and no doubt many other boys, spent a lot of their time masturbating as teenagers, dealing with a powerful physiological need as much as any erotic fantasy. The two are not necessarily present at the same time, though. My friend's voice becomes serious when he says: 'There was a lot of guilt and shame, obviously, tied up with it'.

There is it again: guilt and shame. How many of us managed to get through puberty without a surfeit of either of those two mind-altering substances? And how have we come to make them the collective response to a process so fundamental to human life and as natural as breathing?

One of the interesting aspects of researching puberty is how much more information there is about girls than boys. There is a logical reason for this: boys do not experience an equivalent of menstruation, a kind of epochal moment in the pubertal process: in orchestral terms, when the timpani and cymbals come in for the final crescendo. Menstruation is by its nature easy to measure: most women know when they started menstruating and can describe any problems they had or are having. It is also a complex process, tied up with hormonal health, reproduction, sexuality and other aspects of health. Gonadal puberty, the physical changes most of us think of as puberty, also tends to affect girls more than boys, both physiologically and psychologically.

For boys, puberty creeps up rather more slowly and discreetly, starting with the enlargement of the testes and penis, followed by the sprouting of pubic hair. More obvious is the growth spurt, of course, and the gaining of muscles, a change in the shape of the face and body, and perhaps the appearance of pimples too. Two of the clearest signs of male puberty to the casual observer are the 'breaking' of a boy's voice—that period when it wavers between high and low before settling on low—and the gradual appearance of facial hair. Anyone who is a fan of _The Simpsons_ will know that this is all perfectly captured by the character Steve Freedman, or 'Squeaky-voiced teen', an acne-ridden kid perpetually stuck in a string of dead-end jobs and with a voice that can jump an octave from one syllable to the next.

What we do know is that girls start their pubertal growth 1–2 years before boys, so that by about Year 6 they are often towering over their male peers. We also know that while girls are more likely to experience true precocious puberty, it is boys who are most likely to experience delayed puberty, something that can have a profound psychological impact on them (more on that later). In fact, one of the comments constantly made to me by the doctors I spoke to for this book concerned the anxiety that boys can feel if they don't think they're keeping up with their classmates in terms of their development. Also, the work being jointly undertaken by Melbourne's Murdoch Childrens Research Institute and the Royal Children's Hospital on adrenarche and development—the Childhood to Adolescence Transition Study (CATS)—suggests that this very early stage of puberty, which occurs long before any physical changes make themselves known, seems to affect boys more than girls.

But are boys, like girls, starting puberty earlier than they once were? It is more difficult to be definitive about this, in part for the reason I outlined above: there is much more research available on pubertal development in girls than in boys. Still, while a lot of the research says that what is happening with boys is not yet clear, there is some evidence that they too are beginning puberty earlier.

In 2012, researchers on a large US study involving more than 4000 boys from a range of backgrounds found that the children were starting puberty six months to two years earlier than they were in the 1960s, depending on their race and ethnicity (as studies with girls have found, African-American children tend to start puberty earlier than their white or Hispanic peers). While the researchers acknowledged that further study was needed into the reasons for this shift, they noted that 'environmental factors, including exposure to chemicals, changes in diet, less physical activity, and other modern lifestyle changes and exposures may be related to this apparent rapid decrease in the age of onset of secondary sexual characteristics'—that is, the start of puberty. They also pointed out that, socially and developmentally, young people were heading in the other direction—they were maturing later—so any downward trend in physical and sexual development was significant.

As I argued earlier in this book, if one sizeable group of young people is reaching puberty earlier than before, then in many ways they all are: it shifts the idea of 'normal'. Puberty changes adolescents' relationships, their views of one another and themselves, and their expectations, and, importantly, it brings to the fore their right to know what is happening to them, and how it might affect them in the years to come. But before we look at what is perhaps the trickiest aspect of puberty for parents—the emotional and relationship changes it can usher in—let's look at what happens to boys physically as they make the long journey into manhood.

The start of the pubertal process is the same for boys as it is for girls. In the centre of the brain is the hypothalamus which, when it is time for the body to begin puberty, sends out the gonadotropin-releasing hormone (commonly referred to as GnRH, and you can see why), which in turn triggers the pituitary gland at the base of the brain. The pituitary gland then produces two key hormones: luteinising hormone (LH), and follicle-stimulating hormone (FSH). These hormones work together to encourage the testes to produce higher levels of testosterone, which triggers growth of the penis, pubic hair, facial hair and voice deepening. Eventually, boys reach spermarche—the stage when sperm is produced. This means they have reached sexual maturity, just as menarche signals the same in girls.

**Testicular Volume and Penis Length**

One of the reasons the start of puberty in boys is so difficult to assess is that the first part of the development is largely hidden, even to the boy himself: his testicular volume starts to increase. It may be a little awkward to ask your son over his Weeties if he's noticed any expansion in his testes recently, so it is likely this early stage will go largely unnoticed (or else forever remembered due to an upturned bowl of Weeties on your head).

An interesting aspect of the 2012 US study on puberty in boys I referred to earlier was that the researchers undertook the scientific measurement of testicular volume, using an instrument called an orchidometer: a string of variously sized wooden beads developed by Swiss paediatric endocrinologist Professor Andrea Prader. The researchers found that testicles were starting to develop at just over nine years of age for the African-American boys and just over 10 years for the other boys.

The testes and scrotum grow rapidly during puberty: a pre-pubertal boy has a testicular volume of about 1–3 millilitres; puberty is said to have started when the volume reaches 4 millilitres. Adult men have a testicular volume of about 15–35 millilitres, so as you can see, it's an expansion that continues for some time. It is important to understand that, like breasts in girls, the testes will not necessarily grow at the same pace—it is quite common for a boy to have one testicle that grows more quickly than the other, and this is nothing to worry about. As the testes grow, the scrotum darkens in colour and hangs down further, developing little pimple-like bumps: hair follicles.

The primary biological reason for puberty, of course, is to reach sexual maturity: to be ready for reproduction. For boys, this is when the testes start to produce spermatozoa, a process known as spermarche. A 1986 longitudinal study measured the presence of spermatozoa in boys' urine and compared those findings to their development according to the Tanner scale (as explained in Chapter 2, this is a diagnostic tool that identifies five stages of development in male genitals, female breasts, and pubic hair in both sexes). The researchers found that spermarche occurred relatively early in pubertal development, and across a wide range of pubertal stages. That is, some boys will start producing sperm even before they have pubic hair; for others, this may occur later, at about the same time as the growth spurt.

And now the big one, so to speak: penis length. In cultural terms, penis length is to men what breast size is to women: something many worry about and compare against other people. Yet penis length has nothing to do with sexual function or reproductive capacity, and it is, like so many things to do with our bodies, something over which we have no control.

Early in puberty, a boy's penis will begin to grow: first it lengthens, then it thickens. A lot of boys worry that their penis is not big enough, that it will be a turn-off for potential lovers. This anxiety about penis size can last into adulthood. It can even become a clinical condition known as 'small penis syndrome', a form of body dysmorphia in which a man imagines his penis to be unusually small when it is not.

The reassuring truth is that most men fall into the normal range in terms of penis size. A large study of over 15 500 men found that the average penis is 13.1 centimetres when erect and 11.7 centimetres in circumference. Flaccid penises average about 9.2 centimetres in length and have a waistline of about 9.3 centimetres. OK men, go and dig out the tape measure, I can wait. While I do, just as an aside, an internet survey of over 52 000 heterosexual men and women in 2006 found that 85 per cent of women were satisfied with their male partner's penis size, but only 55 per cent of men were happy with their penis size.

What all of this means is that many boys will worry about whether their penis is the 'right' size, but most of them needn't. So if your son plucks up the courage to ask you about it, reassurance is probably the way to go—there is an excellent growth chart on the website of the Australasian Paediatric Endocrine Group if you want more information.

There are two rare conditions relating to penis size: one involves a penis that appears to be significantly smaller than it really is, and the other involves a penis that is actually small.

The first condition is called 'buried penis', which is when the pubic fat pad, where the penis extends out from the lower abdomen, conceals part or even all of the penis. Often, boys or men with this condition have a normal-sized penis, but it looks very small because so much of it is buried. Dr Phil Bergman, head of paediatric endocrinology and diabetes at Monash Health, says the condition can cause distress, even though there is no underlying pathology; that is, it is not an indication of a medical problem. Males with a buried penis often have difficulty urinating standing up, and the penis is prone to infection of the foreskin. But more than any medical problems associated with it is the big psychological effect it can have, causing a young man a great deal of worry.

In teenagers who are overweight, slimming down might lessen the fat pad and reveal more of the penis, but it won't necessarily be so. Bergman has treated many lean boys who just happen to have a big fat pad that 'buries' the penis.

The other condition Bergman quite often sees is 'micropenis', the naming of which was surely one of medicine's great failures of sensitivity. Micropenis is when a penis is unusually small. This can be caused by a hormonal abnormality or it can be a symptom of a more significant medical condition. The condition is often present from birth and can be treated hormonally with testosterone injections.

While these conditions can be very distressing for the boys who have them, it's important to know that most pubertal boys do not suffer from them. It's usually just a case of giving their bodies time to grow.

**Pubic Hair and Facial Hair**

Pubes. There is no real consensus about what they're for, but we've all seen them clogging a shower drain or lying provocatively on a toilet seat. Some of us have even wondered if that's what we've just found in our restaurant meal (please, no). But in any case, once we go through puberty they are our constant companions, causing women in particular, and more recently men as well, to keep the beauty industry in rude health regarding their removal.

In girls, pubic hair starts to sprout early in pubertal development; it is one of the first visible signs that there is movement at the station. In boys, it develops about one to two years after the enlargement in testicular volume. It starts out as fine, often fair and downy hair, then gradually becomes thicker, darker, coarser and curlier as puberty progresses. In boys, the pubic bush starts at the base of the penis, then spreads outwards and eventually down the inside of the legs. It is worth noting too that, sometimes, boys (and girls) can sprout pubic hair very early in childhood, but this does not necessarily mean they are going through puberty. It is instead premature public hair development, which happens in isolation to other pubertal development. In any case, if pubic hair arrives very early, it is worth having a doctor check it out.

Hair will also become more pronounced on a boy's arms and legs, and it will begin to sprout on his chest (although for many this may not happen until late adolescence, or even into a man's 20s). As testosterone is the hormone responsible for hair growth, some men end up with dark hair over much of their bodies.

If penis length has long been the (misguided) determiner of manliness, surely facial hair comes a close second. For most boys, facial hair starts to develop about two years after pubic hair, and again, it starts out fine and downy before becoming thicker and darker. Facial hair tends to start on the upper lip before migrating to the upper cheeks, then the lower cheeks and the rest of the face. Boys will simultaneously develop hair in their armpits.

**Pimples and Acne**

It's fortunate that hormones have some very good effects, because a lot of the impact they have is pretty unpleasant during puberty. One of the worst in my opinion (because I still suffer from it in middle age) is acne. Most adolescents will have some experience with skin problems at some point. If they're lucky, it will only be mild and occasional. Those who suffer from it particularly badly will need to see a GP or a dermatologist to consider treatments that may be appropriate. (I can also attest to the fact that if it's not addressed early, it can leave scarring, which is obviously not a good outcome.)

The hormones of puberty produce excess sebum, which makes the skin oilier. The skin's pores may also appear larger and become clogged by excess skin cells and sebum, which triggers the growth of acne bacteria. This happens in concert with inflammation of the skin and causes a pimple. Sometimes a person is particularly prone to this and they can find themselves dealing with full-blown acne.

There is still considerable debate about what causes acne, and what makes some people more susceptible to it than others. There is clearly a genetic link: if there is bad skin in your family, your risk of having it increases. Diet is a contested area, even among scientists, though some people who suffer from acne swear that it matters. While it is important for teenagers to practise good personal hygiene and wash their faces regularly, acne is not a sign of dirtiness. Rather, it is a sign that the body is growing and hormones are having an effect on the skin.

Acne can be painful, and it can be embarrassing, making a young person feel very self-conscious. If a boy is at all distressed by his acne, it is worth seeing a doctor about it. It's also worth giving your son the advice your parents gave you, and which their parents probably gave them: as tempting as it is, it's best not to squeeze—acne is a minor infection and it can be spread.

**Odour**

If boys worry most about their penis size and facial hair during puberty, one of the most often noted aspects of their development by their parents is how much they can smell. They're gorgeous, of course, and smart and funny and all the rest, but boy do they pong sometimes. Walk into a young man's bedroom and feel the aroma smack you across the head: lots of sweat, sometimes with semen thrown into the mix.

Boys can be a bit smelly even before puberty hits, but once the hormones ramp up, so does the odour. The sweat glands start to produce more sweat than they used to, in particular the apocrine sweat glands, which are only triggered by the hormonal changes of puberty. Sweat is also increased by high emotion, stress and sexual arousal. That sweat comes into contact with bacteria on the skin, which breaks down the sweat and causes odour. In fact, bacteria love sweat, which is why foot odour can be such an issue—it's why you have to put those runners he loves so much at the back door because you can smell them from the next suburb.

We all know how the smell can be minimised: regular showering, use of deodorant, and keeping clothes clean. To some extent, though, it's just the body's natural response mechanism, and we have to live with it.

**Breast Development**

This can be a sensitive issue for boys (and men), not helped by the ridicule around 'man boobs' or, in keeping with our compulsion to shorten everything, 'moobs'. On a more serious note, people are often surprised to hear that men can develop breast cancer. While it is not common, it does indeed happen, because men have breast tissue.

Oestrogen is the trigger for breast development, though boys may not even be aware that they have low levels of oestrogen in their bodies before, during and after puberty. It is also vital for bone density and the development of the larynx (voice box), which will later lower a boy's voice to its manly pitch. Some testosterone is converted to oestrogen in the body by an enzyme called aromatase. Too little or too much aromatase can consequently have a big effect on oestrogen levels in a boy. For example, oestrogen is the hormone responsible for stopping our growth (eventually), so boys with low levels of aromatase can end up very tall. Similarly, excess aromatase can be treated with aromatase inhibitors in boys with short stature, or who are experiencing precocious or delayed puberty, to ensure they reach their full height.

There are two kinds of 'breasts' in boys, which are often confused. The first is simply excess body fat, so overweight boys are more likely to have 'breasts' than boys of normal weight. Understandably, some boys become very anxious about this, worrying they are 'turning into a girl'. It's not so, of course, but it still puts them at risk of teasing and bullying—all good reasons for reassurance in the first instance, and medical advice if the issue is of particular concern.

The second kind of breast development in boys is called gynaecomastia. This is where there is actual developed breast tissue rather than just fat (this can be determined through an ultrasound). Just like girls when they develop breast buds, boys can often find that the tissue around their nipples is hard and painful in early puberty. More than 40 per cent of adolescent boys will experience some kind of breast development, caused by their bodies converting some of their testosterone into oestrogen and then the breast tissue being particularly sensitive to that oestrogen. (Baby boys can also sometimes experience gynaecomastia, caused by the absorption of an excess of oestrogen from their mothers, but again this mostly resolves itself.) There are also some genetic causes of gynaecomastia, such as Klinefelter's syndrome (discussed in the next chapter), and it can sometimes be caused by a chronic disease.

Dr Phil Bergman sees many adolescent boys who are worried that they have breasts. Sometimes, he says, the breasts are very small, and the only thing that can be done to reassure the boy is to let him know that this is very common, and that most pubertal cases will resolve themselves once the hormonal changes level out—although a few men will continue to have the condition into adulthood. However, sometimes the gynaecomastia can be severe, resulting in clearly noticeable breasts. Often, the afflicted boy will sit hunched over in Bergman's office, his shoulders rounded from constantly trying to conceal his breasts. In such extreme circumstances, Bergman will refer the boy to a plastic surgeon to consider breast removal.

**Growth Spurt**

Oh, boy, look at him go! I have a vivid memory of a male friend at university explaining that, as a teenager (and even into his early 20s), he felt hungry all the time. As in, there was never a time when his stomach wasn't growling or he wasn't fantasising about a double-decker sandwich or a pie with chips. The rate at which young men grow and burn energy is, in some cases, truly a sight to behold. The parents of teenage boys can drop a small fortune on a week's worth of groceries, only to find it all pretty much hoovered up by the following morning.

The growth spurt for boys happens in the middle of puberty, usually around 12–14 years of age. In general, boys' growth spurts happen later, are bigger, and last longer than girls'—most boys stop growing at about 18–20 years old. At peak pubertal growth, boys grow 7–12 centimetres a year—which goes some way to explaining why they are hungry all the time.

One of the ways in which puberty makes fun of us all (gently, of course) is that, for boys and girls, growth does not occur evenly. The hands and feet are often the first to lengthen, with the head expanding too. The limbs, body and shoulders catch up later. This is where the classic 'gawky' teenager look comes from—boys will sometimes be made quite clumsy by their new proportions (also by the fact that they're really thinking about whether they can get to the next level on a new game, not about stacking the dishwasher).

And just as a girl's body shape changes during puberty, so does a boy's. While girls' hips widen and breasts develop, boys' shoulders and chests expand, and they often take on muscle or 'fill out'.

**Spontaneous Erections and Wet Dreams**

If you have a son, you may have been surprised to notice him having an erection when he was a baby or toddler. This is normal, but it's rarely talked about because an erection is so strongly associated with sex—it's not something we imagine happens to babies. We don't like to think that we are sexual beings from the moment we enter the world, of which erections in small boys are just one aspect. Sometimes it happens for no apparent reason; other times it's because the boy is touching his penis. In any case, it's nothing to be concerned about.

During puberty, as a boy progresses to sexual maturity, he's going to have sexual desires, be more interested in masturbating, and will now be able to ejaculate. The truth is there's not much a guy can do about unwanted erections, except try to conceal them if that makes him feel less self-conscious. Eventually the erections will settle down and only happen when he's sexually aroused.

Sometimes that first ejaculation will happen at night, when the boy will wake to find a wet patch in his bed or on his pyjamas—these are the famous wet dreams. Again, this is perfectly normal and nothing for him to be embarrassed about. Wet dreams too will settle down with time.

There is a lot of sensible, practical advice on the internet and in books, written for young people, if you want to give your boy something to read to reassure him about erections and wet dreams. The worst possible source of his sexuality education is pornography—not just for the physiological expectations, but equally importantly about relationships, particularly how men treat women—so it's best to be proactive about this. Again, I don't mean thundering down on a young man and telling him not to look at pornography, because that won't work. I'm talking about having a conversation about what he's seeing, how distorting it is, and presenting informed accurate counter-information.

**Voice Breaking**

This is one of the later stages of puberty for a boy. As he grows up, his larynx becomes larger and his vocal cords also lengthen and thicken. Eventually, all of this causes his voice to deepen. But in the (relatively short) time it takes for this to develop, his voice might 'crack' and suddenly shoot from high to low and back to high again—or he might experience a slow and gradual deepening of his voice that doesn't involve much wobbling at all. Whatever the case, it's all part of becoming a man. And there's always the chance he may develop a beautiful rich baritone or tenor singing voice in the process.
Chapter 11

**Pubertal Problems for Boys**

WE ARE COMPLEX animals, and at each stage of our development there are things that can go awry. Puberty is no exception. Much of this book has been devoted to looking at whether, at a population level, children are starting puberty earlier than they once were, and the fact that all the evidence points to the answer 'Yes'. But within the big picture is a vast range of individual experiences, including going through puberty early (precocious puberty) and going through it late. In many cases, early and late puberty will still be within the normal range, and nothing to worry about. However, sometimes there are underlying reasons as to why puberty has been hastened or delayed, and these warrant investigation.

Girls are more likely to experience precocious puberty than boys; conversely, boys are more likely to go through delayed puberty. Because girls generally start puberty earlier than boys anyway, this means that a boy whose developmental train is slow to pull out of the station can still look like a little boy when he's well into high school. This can cause him a great deal of distress and anxiety, which is not to be taken lightly—although at the same time, it's important to remember, and to remind him, that in most cases this is perfectly normal. And of course, if a more serious problem is causing the delay, it will need to be fully examined and treated.

**Precocious Puberty**

True precocious puberty, rather than just a lad at the early end of the spectrum, is when a boy starts to develop before he is nine years of age (in girls, it is before she turns eight). As I mentioned in Chapter 10, it can be difficult to know when a boy has reached this stage. Obviously, you're not going to know if his testicular volume is increasing, so the first sign that precocious puberty is happening might be pubic hair or acne or perhaps even a growth spurt. Sometimes pubic hair, for example, may emerge early, but the rest of his pubertal development happens later, at a more standard time (this may not be precocious puberty but precocious pubic hair development; in any case, it is worth a trip to the doctor).

The trouble with early puberty in boys or girls, apart from making them stand out from their peers, with the distress, teasing and/or behavioural problems that may engender, is that early growth spurts can result in an advanced bone age. If early puberty is diagnosed in a boy, the doctor may order an X-ray of his left wrist to check the age of his bones and determine his likely final height. This is because children who go through puberty early can sometimes end up shorter than they would have been if they'd gone through puberty at the normal age.

Rare, underlying pathologies can also trigger puberty early in boys, most notably tumours or cysts in the brain. Dr Phil Bergman is the head of paediatric endocrinology and diabetes at Melbourne's Monash Health. He says that precocious puberty in boys is far more likely to have an underlying pathology than it is in girls, simply because it's so unusual, and that the converse is true of delayed puberty, with girls more likely to have a condition that is causing it. However, he stresses that many of the young people he sees fall within the normal variation of puberty, and often there's a genetic connection: someone else in the boy's family went through puberty early too.

**Delayed Puberty**

This is much more prevalent in boys than in girls (or perhaps it is just that boys—or their parents—are more likely to worry enough about it to seek treatment). It is also more common than precocious puberty. If a boy is not showing any sign of development by the time he is 14 years old, his puberty is delayed and it is worth having him assessed by a doctor.

Sometimes it will be simply because there is a family history of late development. Surprisingly, it's not just to do with his dad but can also be influenced by how late his mum started puberty. The American Academy of Pediatrics says that in about two-thirds of cases of constitutional delayed puberty (as this kind is known), the boy has inherited this predisposition from one or both parents. The good news is that if the boy is otherwise healthy, puberty will eventually happen—he just has to hang in there.

Delayed puberty may be caused by high stress, eating disorders such as anorexia nervosa, or excessive physical activity (these factors can also apply to girls). These are some of the first conditions a doctor will investigate. Beyond these, a chronic condition such as sickle cell disease, inflammatory bowel disease or diabetes can also hold puberty back—over his 20-year career, Phil Bergman has diagnosed Crohn's disease and coeliac disease in boys who have presented with delayed puberty. Malnutrition, weight fluctuation and infection can also have an impact on the timing of puberty.

Bergman says that part of his assessment of a boy with no sign of puberty will be to try and understand if the boy's brain is producing the hormones that trigger puberty. If it is not, then there may be cause to send him for a scan to rule out a brain abnormality such as a cyst or a tumour. If his brain is in fact producing puberty hormones but nothing is happening, then the problem might be in the testes, which may not yet be making hormones at sufficient levels to trigger the physical changes of puberty.

One of the aspects of delayed puberty that is often mentioned in the literature, and that doctors talk about a lot as well, is the psychological impact it can have on boys. They worry about being shorter, thinner and less muscular than their friends. In many ways, boys suffer from a narrower idea of their gender role than do girls—many boys are kept on a tight leash of gender norms from the day they are born and someone wraps them in a dinosaur blanket. The idea of 'manliness' is no less restrictive, and young boys feel this keenly from an early age. For boys whose development takes its sweet time, this can be particularly distressing as they look at their bigger, hairier friends with deeper voices. There are also fears about sexual attractiveness, which boys may mistakenly believe correlates with how much a guy conforms to the masculine ideal. Australia's sporting culture, which idolises a large, muscular physicality, contributes significantly to the feeling that something is 'wrong' with them if they are smaller than their friends. Overall, boys probably get overlooked in the body image debate—while I still believe it is far more pernicious for girls, there is no question that boys are increasingly affected.

All of which is to say that the emotional distress that delayed puberty might cause a young man is not to be ignored or dismissed as trivial. And help is at hand: good doctors are acutely aware of the need to treat the whole person, and even if no medical intervention is deemed necessary, it can still be comforting for a boy to hear from a professional (rather than Mum and Dad) that he is perfectly normal, and that puberty is one of those things in life over which we have little control.

**Klinefelter's Syndrome**

The most significant chromosomal disorder associated with delayed puberty, Klinefelter's syndrome, is a genetic condition that affects only males, who are born with an extra X chromosome. So instead of the XY combination that creates 'maleness', they may have, for example, an XXY arrangement. Klinefelter's is not an inherited condition but rather one that can arise randomly as the cells are dividing soon after fertilisation.

Andrology Australia, a group interested in all things to do with men, hormones and health, says that Klinefelter's affects about one in 650 Australian males, but that some may never be diagnosed with the condition. A Victorian study in 2011 found the prevalence at birth to be about 223 per 100 000 males (or about one in 448), and that 50 per cent of cases were undiagnosed.

The primary effect of Klinefelter's is that men cannot produce as much testosterone as they need. Testosterone plays a very important role in men's health and wellbeing (and women's, for that matter), and this means that a boy with Klinefelter's may have a range of symptoms of differing severity, depending on his particular genetic make-up. He is likely to have small testes, gynaecomastia (breast development), fatigue, low libido (sex drive) and weaker bones, and to be taller and curvier than his peers, have less body and facial hair, and experience weak erections. Klinefelter's cannot be cured but is instead treated with testosterone therapy to counteract the body's inability to make sufficient amounts of the hormone.

Unfortunately, in addition to low testosterone, men with Klinefelter's are usually infertile, as there is no sperm in their semen; the testosterone therapy will not address this. However, sperm can sometimes be found in the testicular tissue, so IVF treatments, in particular intracytoplasmic sperm injection (ICSI), are available for those wishing to become fathers. Professor Gab Kovacs, an IVF specialist, says there are several options for harvesting sperm from men with Klinefelter's, ranging from a needle biopsy into the testicles under local anaesthetic, to more invasive treatment in which a section of the testicle is excised and then searched in the laboratory for sperm. A less invasive biopsy also can be performed using an operating microscope to identify small groups of sperm.

Kovacs estimates, however, that only in about 10–20 per cent of cases of Klinefelter's syndrome are the scientists able to find sperm. And in his experience, the larger the testes, the better the chance of finding some. More often, couples explore the use of donor sperm to conceive.

In childhood, Klinefelter's can also be responsible for learning and behavioural problems, and poor muscle tone. It may not be a condition that doctors immediately suspect when presented with these symptoms, however, so it's worth asking about if your son is displaying some of these signs.

**Helping Boys to Be Comfortable with Their Bodies**

The aforementioned issues are the physiological impacts of puberty on boys. The trickier aspect of puberty—the one that, from the many conversations I've had on the topic, parents worry about the most—is the psychological impact of sexual maturation.

It can be difficult to predict who is going to struggle with puberty and who is going to cruise through it. And, of course, puberty doesn't happen in isolation but rather in the context of changing social conditions, intellectual development, the gaining of independence from parents, family circumstances, and a growing awareness of the world. Boys and girls alike struggle with peer groups, their sense of themselves (who they are), and what role they may play as adults.

Adolescents, too, in a sense can be quite unaware of how young they are. This is not to disparage them in any way, but simply to point out that for many, their lives are largely made up of school, friends, family, perhaps a part-time job and then a social life. Boys are more prone to risk-taking behaviour than girls in adolescence, although both certainly do it—experimenting with drugs, sex, alcohol and dangerous activities.

But while parents rightly worry about what their sons might be up to, there are strategies they can employ to help them cope with it (these will be discussed in greater detail in the next chapter), and as always there is professional help available too. And it should be remembered that, no matter how uncommunicative, secretive or outright hostile your adolescent son might be, in most cases it is just a normal, if frustrating, part of growing up. That said, there are certainly situations where something more serious might be going on, when the trick is to be aware of it, trust your parental instincts, and as always, seek help if needed.
Chapter 12

**Grunt Work**

Boys' Social and Emotional Development into Men

_Give me a child until he is seven and I will show you the man._

Aristotle

IN ARISTOTLE'S TIME, the fourth century BCE, adolescence was unheard of—it was not yet invented, you might say, and wouldn't be for many hundreds of years. But for a long time, this maxim was held to be true in terms of human brain development: that the early years were crucial, but after that, not much happened. That view no longer holds. We now know that brain development continues through puberty, the 20s and even up to age 30. These days, Aristotle might change his saying to 'Show me a fellow at 27 and I'll show you the man', which honestly is nowhere near as punchy or profound as the original expression. Still, it's more accurate.

A key reason we understand so little about the adolescent brain is that, up until recently, the only way for scientists to meaningfully study it was through a post-mortem. But since the invention of safe, non-invasive investigative techniques such as functional MRI, scientists have been able to learn more about the remarkable and complex development of the human brain. One of those leading the way in understanding the adolescent brain is British neuroscientist Sarah-Jayne Blakemore. The work she and her peers do has profound implications not just for how we treat and talk to young people, but how we educate them too.

One discovery in this area is that, basically, the brain takes much longer to develop than the body, so that even when a boy is 18 years old and finished with puberty, his brain is still building connections. And Blakemore says there is now convincing evidence that puberty itself has a significant impact on brain development—there is a closer alignment here than with chronological age. In her wonderful book _The Learning Brain: Lessons for Education,_ Blakemore explains that during adolescence, the brain undergoes a significant reorganisation. 'If 0–3 years is seen as a major opportunity for teaching', she writes, 'so should 10–15 years. During both periods, particularly dramatic brain reorganisation is taking place'.

Using fMRI, scientists have detected that it is the frontal cortex in particular that is slow to develop, and which keeps evolving long past childhood. The frontal cortex is responsible for our so-called 'executive functions', which include abilities such as inhibiting inappropriate behaviour, multi-tasking, planning, and holding information in the mind. So while these functions are improving during adolescence (possibly noticeably so), they will keep developing long after puberty has ended.

Another interesting observation Blakemore and her colleagues have made, in a separate study, points to the misunderstood role of testosterone in young men. How often have you heard someone say, in relation to hoonish or violent or dangerous behaviour by young men, that 'It's all that testosterone'? Well, it seems that poor old testosterone—a hormone that is important to both men and women for a range of functions, including libido, mood and the growth of muscles and bones—is unfairly fingered in a lot of these cases. Blakemore argues that 'while testosterone levels increase during puberty, aggressive behaviour does not show any simple relationship with testosterone during adolescence'. (The relationship between testosterone and risk-taking, on the other hand, may be a bit different, as I talk about later in this chapter.)

In other words, testosterone does not make boys aggressive as such. The association is rather more subtle: testosterone 'increases motivation to achieve higher status, but the specific effects on behaviour are _dependent on the social and developmental context'_ (my emphasis).

Professor Robert McLachlan, head of clinical andrology at the Hudson Institute of Medical Research in Melbourne, also believes that testosterone has had a bad rap. 'Although people link the hormone with aggression, this hasn't held up under scrutiny', he writes. 'Rather, research has shown testosterone levels are associated with quite different traits, such as care-giving and empathy.'

So what we have when a boy reaches puberty is a pretty volatile combination of conditions. His brain is not yet fully developed, and won't be for some time. His body is undergoing huge physiological changes, some of which he may find acutely embarrassing or even shameful. His sex drive is emerging (and he may be questioning his sexuality), his impulses are changing, and his relationships may be re-forming around him. Add to this mix a highly sexualised culture, some pervasive and damaging ideas about masculinity and 'maleness', and the still relatively new pressures of social media and constant interaction with friends, and it's little wonder that some young men struggle to find a strong emotional foothold.

Adolescence is also the time when serious mental health issues can come to the fore, with about half of an individual's mental health problems becoming prevalent by the age of 14. Mental health group beyondblue reports that about one in four young Australians has a mental health condition (this includes substance abuse disorders), while one in six suffers from anxiety, and one in 16 from depression. About one in five Australians will experience a mental health condition in any given year, and young people aged 18–24 have the highest prevalence of mental illness of any age group.

LGBTI young people can suffer acutely in all of this, particularly where they fear the reaction of family and friends to their coming out, how this might change their relationships. They may also come from religious or cultural backgrounds that make coming out even more difficult. We know that LGBTI young people are at far higher risk of depression, anxiety and suicide—just as we know that one of the best antidotes to this is a supportive family and school environment. Refer to suggestions by psychologist Dr Michael Carr-Gregg on key ways in which parents can support their kids in coming out.

We also know that mental health more generally is an issue of great concern to young people themselves. A 2016 survey by Mission Australia, a community service organisation, found that 15–19-year-olds ranked mental health as the third biggest national issue (just behind alcohol and drugs, and equity and discrimination). Of course, a little bit of male adolescent angst is nothing to worry about. Rather, it's the persistent low mood, lack of engagement in activities he once enjoyed, and overall lack of energy that is worth investigating.

There is strong, widely accepted evidence that girls who experience early trauma—in the form of abuse, violence or hardship, for example—are more likely to have their period start early. There is thought to be an evolutionary reason for this, namely that the instinct to survive prompts the body to transition into adulthood sooner than it otherwise would. Evidence recently came to light suggesting that this applies to boys as well. In 2013, Professor George Patton and his colleagues from the Murdoch Childrens Research Institute, studying data from the Longitudinal Study of Australian Children (LSAC), found that children who started puberty early—by the time they were eight or nine—were more likely to have had behavioural, social and emotional problems earlier in their lives.

What this means is that this group of children is at greater risk of developing mental illness as they make their way through the often-trying pubertal years, at least partly because, due to their backgrounds, they have fewer resources and less support to draw on. So while we may worry about the boy who comes to puberty late, we also need to be mindful of the boy who starts on that path early, because of the psychosocial stresses that may accompany it.

One of the deceptive characteristics of kids who develop early is that they no longer look like kids, and this can change (even if subtly) the way we deal with them and what we expect of them. Yet no matter what the exterior looks like, they are still children—children who will have the same emotional and social skills as many of their peers. Carr-Gregg likens it to a car that has the outside appearance of a modern vehicle but a learner driver behind the wheel. An 11-year-old may have pubic hair and a deep voice, but he's still an 11-year-old. We need to remind ourselves of that when we speak with, or instruct, boys who have developed early.

And what of the risk-taking? What about that propensity young people in particular have—and, let's be honest here, which most of us had when we were their age—to make bad decisions: to get in a car with a driver who's been drinking; to play 'chicken' on the road at night; to do things that would keep their parents awake at night, if they knew about them?

Boys' tendency to take greater risks is often linked to testosterone, which is present in boys at 10 times the levels seen in girls. In 2013, Dutch researchers published a study that looked at gender differences in risk-taking, matched with testosterone levels. Boys with higher levels of testosterone showed a greater willingness to take risks, while girls with more testosterone took greater risks but in a way that was advantageous to them. In other words, there may be something about the structure of the male brain that results in puberty amplifying risk-taking, while it suppresses the impulse in girls.

Adolescent psychologist and author Andrew Fuller says that in evolutionary terms, that tendency to greater risk-taking may have worked in men's favour. It is reasonable to assume that, in ancient times, physical courage was needed to forge new lands, hunt animals and protect the tribe. Regarding contemporary risk-taking, Fuller suggests that parents ask themselves three questions about their son's psychological health, to help determine whether, and when, they ought to be worried—and by this, I mean seek help; worrying alone rarely achieves anything constructive.

_Is my son different?_ To put it another way, does he seem to have undergone a distinct transformation in his personality? That said, some change during puberty is to be expected. It is a significant time in a person's life—a time when, as I discussed earlier in this book, huge physiological and social changes are happening. Part of a healthy adolescence is the development of a distinct personality, the forging of independence from a family. So some withdrawal, and a desire for privacy, is perfectly normal. As Fuller points out, the standard teenage boy response to a question like 'How was school?' will pretty much always be 'OK', because he's unlikely to tell you about a fight he may have had with his friends, how he finds a girl or boy in his class irresistibly attractive, or how Johnno got a surprise (and hilarious) boner during English class. Sometimes, he just won't feel like talking to you. The trick then (as with so much of parenting, frankly) is to not take it too personally.

_Is it a change that occurs across different settings?_ A lot of parents talk (with no small degree of irritation) about how different their teenager is at home compared with the way he is with his friends. At home, he might be surly and uncommunicative—the old monosyllabic answer to every attempt to engage him in conversation, assuming his eyes can be pried away from his screen of choice. But when he's out with his mates, he's the life of the party. This, too, is normal behaviour and, as frustrating as it might be, it's not something to be concerned about. However, if a boy's low mood is also evident at, say, school or extracurricular activities, or even when he's out with his friends, then it is vital to seek help.

_How worried are you about him?_ This is an important question. Ask yourself what your parental instincts are telling you. You know this boy better than anyone. If you think something is wrong, it's best to check it out, even if only to be reassured that he's just being a teenager.

Even if a boy doesn't develop any mental health issues, there's no doubt that adolescence can be a tough time, especially when it comes to social media. Much has been said and written about the at-times pernicious effect social media can have on young people. Hanging on to every post, waiting to see if you get enough 'likes' and 'shares', can be a trap even for adults; for young people it can be perilous. The problem is that their sense of themselves, and validation of who they are, is coming from external sources. Worrying about whether your friends like you, whether you're cool, is not a new phenomenon for young people. But having all this displayed so publicly, and being so vulnerable to bullying and exploitation, certainly is.

There are sensible precautions that you, as a parent, can take. You can, for instance, insist on being 'friends' with your son on social media before you allow him to have an account, and you can limit the amount of screen time he can have when he's at home. But this is very difficult to regulate, especially as he travels deeper into his teenage years. There's really little point in trying to defeat social media—that is a forlorn pursuit. It will not simply go away; in fact, it will likely become even more invasive and pervasive than it is now.

Instead, there are skills you can help your son develop to cope with social media's pitfalls, to enjoy it and not be hurt by it. Andrew Fuller talks in particular about resilience, one of the greatest skills we can give young people. Resilience refers not only to a boy's internal resources—reasoning, calmness, contextualising, courage—but also to the support he has around him. In their large study of 160 000 adolescents in Australia, Britain and Bhutan, Fuller and his colleagues at the Melbourne-based organisation Resilient Youth have found that children who have better-developed social and communication skills are more likely to have high levels of resilience.

Which brings us back to that old point: communication. Talking to kids, giving them age-appropriate information, trying as best as we can to normalise their experience, to listen to them, to minimise the potential for shame and embarrassment. Boys, like girls, need information. They need to know what is happening to them, how it is likely to change them, about some of the more challenging aspects of growing up. They need to know about drugs, alcohol, driving, the law, relationships, sex, friendships, sexually transmitted infections, pregnancy, violence. They need to know that pornography is not a good depiction of sex or relationships, particularly with women. They need to know that being gay or bisexual is just fine, and that their parents love them no matter who they are attracted to. They need to develop the courage to say no and to be their own man. They need to have condoms in their wallets and in their bedrooms.

They need examples around them of good men, who don't necessarily conform to the macho stereotype. They need to see men being nurturing and caring, and doing housework, as well as playing footy, fixing the tap or taking the bins out. I'm not suggesting they need to retreat to the forest, put on war paint and play the bongos, simply that they need to see a wide range of men and masculinity around them so that they are not suffocated by any daft or obnoxious stereotypes. They need to know that it's OK to be gentle or nerdy or sensitive, that it doesn't undermine their masculinity.

They need to have supportive, patient and honest parenting, which helps and guides but is also not afraid to set boundaries. And they also need to have had good-quality sexuality education at school right from the early primary years, long before they even know what a condom is.
IV

Sexuality Education: the Urgent Need for Reform
Chapter 13

**Beyond the Birds and the Bees**

_I don't think we talk about it openly enough. I've never had an issue with discussing puberty or sexuality and I still feel there is some unnecessary self-censorship around the topic._

Michael, 44

_I think we're getting better at talking about puberty more openly. Sexuality education in schools has improved significantly and there are many excellent resources for kids to access. But at the same time, many parents find these topics really challenging to talk about with their kids, and many people find it very difficult to have to confront and acknowledge their children's emerging sexual development._

Sally, 53

MICHAEL AND SONYA are both friends of mine, but let's not hold that against them. Their views echo those of many adults around the country. Even though sexuality education has improved markedly since I was at school in the 1980s, it's still something that is handled in too piecemeal a fashion and is too susceptible to being spooked by those who disapprove. Australia is in desperate need of consistency, courage and reform on the issue.

There are some complex reasons for the current situation. The first and most obvious is that sexuality education has always been, and continues to be, a difficult topic for parents and teachers—and politicians—to tackle. While there are guidelines for schools that are implemented through the national curriculum, as well as state-based guidelines, how schools teach sexuality education is largely left up to them. Depending on the kind of community they are serving, the response from the parent group, the beliefs of the principals and the available budget, some schools may have a thorough and comprehensive sexuality education curriculum, while others might do next to nothing.

It is not an easy subject to teach. But it would be a lot easier if teachers were properly trained in it. One of the refrains I hear when talking to the experts about sexuality education is the paucity of high-quality training in the subject to give teachers confidence, and allay any anxieties about upsetting parents by saying something they 'shouldn't' (or that is factually wrong).

Upsetting parents is a legitimate concern. In an era in which a complaint about a school can quickly go viral on social media, schools are wary of attracting the wrong kind of attention. This in turn makes them distinctly risk-averse, and sexuality education is one of those flashing-amber-light areas. While a lot of parents are likely to be supportive of an age-appropriate sexuality education program, especially if it is explained to them in detail, it is often a vocal minority that holds sway. This is particularly so at the primary-school level (few people would be surprised that sexuality education is taught at secondary school), where it's still done tentatively and on an ad-hoc basis, with many schools not talking to kids about puberty until Year 6. As the earlier chapters of this book have demonstrated, that is far too late. By then, the puberty horse has well and truly bolted.

Gabrielle Leigh is the most recent past president of the Australian Government Primary Principals Association. Over a long coffee in the shadows of the Victorian Parliament, Leigh admits that many primary-school principals are afraid of negative publicity, and that makes them extra cautious when dealing with sexuality education. 'People [primary principals] are just saying it's really hard to do anything effective', she says.

I'll come back to this issue later, and how we might resolve it. For now, I want to mention a second, harder-to-fathom reason why schools are reluctant to embrace sexuality education at the primary-school level: we're all still so damned uncomfortable about talking to kids about their bodies, our bodies—any bodies, really—and sex. Australians have a weird hang-up about this. We are so broad-minded and liberal in some ways, so conservative and crush-ingly shy in others. Whether this is some peculiar hangover from our colonial past or a strange little idiosyncrasy of our own is hard to say, but whatever the cause, it does not serve us particularly well.

Before I go on, a quick note on terminology. The term 'sex ed', which is what people of my generation would recognise, is a bit dated. These days it is often referred to as comprehensive sexuality education, or CSE. The idea behind this name is that it emphasises a holistic approach to sexuality, relationships and emotional wellbeing, rather than simply the mechanics of reproduction. I take this point, and agree that it needs to be broad-based. But because I'm not a fan of jargon, and the 'comprehensive' part ought to go without saying, I will refer to it simply as sexuality education.

I have some vivid memories of sexuality education at school, a subject I always enjoyed, partly because these issues were rarely spoken of at home and this was a chance to learn something. (In fact, I have a clear memory of being in Year 5 and innocently asking my mother, just as we approached our front door one afternoon, what a period was, and being firmly shushed in case the neighbours heard.) I remember us all sitting cross-legged on the classroom floor in Year 6, watching a strange, otherworldly video about pubertal changes, which ended with pubescent boys and girls standing around a swimming pool with no clothes on, then jumping in. It was like an odd initiation into a cult rather than a sexuality education video, and it's still in my mind 30 years on. And while our teachers did not do the condom-on-the-banana trick—I guess that was considered a bit racy—I am grateful to the kindly teacher in Year 8 who showed us how a tampon worked by dropping it into a glass of water. We watched in wonder as its white fluffy body took on the water and expanded; David Copperfield probably has never had a more captivated audience.

I also remember much giggly discomfort when we received a letter to our parents explaining where we were going on school camp—the absolute highlight of the year—and that some girls might need to bring sanitary products (I'm pretty sure that was the term used), just in case: all that fresh air, hiking, camping and what not. We were not spoken to directly about this. It was just mentioned in the letter, alongside the wet weather clothing, extra socks and toothbrush. We spent the whole of that afternoon's maths class talking sotto voce about whether we would take pads with us or not, and getting unduly excited about the whole thing.

This is a perfect illustration of why we need better sexuality education. To us schoolgirls at that time, the thought of a period—to those of us who were yet to experience one, anyway—was something fascinating and embarrassing, rather than what it should have been: something normal, natural, interesting, comfortable. We were anything but comfortable. Thrilled, embarrassed and intrigued, yes, but certainly not comfortable.

The other great source of information about puberty and sex for me was the Judy Blume books. Where would my generation have been without Judy's frankness and wisdom? We all loved them. _Tales of a Fourth Grade Nothing, Blubber,_ and the special favourite: _Are You There, God? It's Me, Margaret._ We were so obsessed with Judy Blume (and Roald Dahl of course, though not for finding out about puberty) that it was a sure-fire winner as a birthday present in my middle primary years. So when I was invited to my twin friends' 10th birthday party, my mum dutifully took herself down to the bookstore and came back sporting a Judy Blume novel as a present. She was mortified to later learn that she had chosen _Forever,_ the book that was about 16-year-olds losing their virginity. Good times!

_Dolly_ magazine was also a great source of information—and always high quality. A recent study by the University of Newcastle, which assessed the health information of 10 popular magazines for accuracy, scored _Dolly_ the highest, at 100 per cent no less. It's hugely popular 'Dolly Doctor' section, most recently written by Associate Professor Melissa Kang, a Sydney-based adolescent health specialist, for years dispensed immaculate health advice. It's a shame that _Dolly,_ no more immune to the changing media landscape than any other publication, shut down its print version late in 2016 and now appears only online.

In my primary-school days, of course, no-one I knew had a computer, and the internet was still years away from bursting into glory. In technology terms, we thought we were living on the edge with an Atari that we hooked up to our old dial TV to play Space Invaders. Then, when my brother and I each received a Game & Watch for Christmas—he the double-screen (jealous!) Donkey Kong while I got Octopus—we thought we had surely reached the outer limits of technological advancement. And that was only 30 years ago. Needless to say, children today are growing up in a vastly different environment. In 2014–15, 97 per cent of Australian households with children under 15 years of age had access to the internet. Just think about that: 97 per cent. Now, it is probably higher still.

As we all know, the internet is a vast wonderland of riches and pitfalls. Just as easily as young people can find a sober, scientific account of menstruation, they can find a hateful, bile-filled rant against women and their bodies. Or something about puberty, written with the best of intentions, that is simply wrong. One of the comments that teachers and principals made to me again and again in the course of my research for this book was how 'knowing' kids are these days: how much earlier they come into contact with 'adult' ideas and concepts. Dolly Doctor Melissa Kang tells me that what she notices—and bear in mind she communicates directly with kids on this topic all the time in her medical work and her _Dolly_ column—is how familiar kids are with sexually explicit and anatomical words. For example, they know the difference between 'labia' and 'vagina'; they talk about the breast, nipples and areolae. They are confident, knowing, asking about sex and masturbation far more than young people once did (publicly, that is).

Now in many ways, it's heartening that young people are using the correct terminology rather than slang, which is so often imbued with fear, disgust and sexism. The worrying aspect is the fact that they are gleaning this information from each other or the internet, especially, as Kang points out, as so much of the pornography they might come across is aggressive and misogynist. The answer? Well, Kang too believes that comprehensive sexuality education is the key, and that it should start from the middle primary years. This education would be age-appropriate and begin with an understanding of the body, identity and relationships (in the general sense), progressing through puberty and eventually arriving at sex.

So here we are again at the old impasse: childhood is changing, both experientially and physically, yet we continue to pretend that it isn't. Sexuality education is conducted in an ad-hoc manner, sometimes good and sometimes bad, which means that some kids are lucky and others are left in the dark. Similarly, some parents tackle the issue, while others would rather not. Even parents with the best possible intentions may not give 'the talk' as well as they would like, or their kids would like. Certainly, kids themselves would like to know more, and sooner. A 2012 study by the University of Ballarat of about 100 students found that more than half of the years 7, 8 and 9 students thought topics such as puberty and pregnancy should be introduced in primary school.

In some ways, the times are against a more open and liberal approach to sexuality education—although this is all the more reason to fight for this. In the past year, there has been a seismic shift in the global political landscape, and a smaller but nonetheless significant one here in Australia. These things matter, because education always occurs within several interlocking and overlapping contexts: the community, the country, the times. If 2016 will be remembered for anything—apart from its penchant for killing off celebrities—it will be for the global twist to the right, away from establishment parties and ideas and into an embrace of right-wing populism. This was exemplified by the stunning win of the Brexiteers in the United Kingdom, and the even more surprising win of Republican nominee Donald Trump in the US presidential election. Conservatism is on the march.

In Australia in 2016, we saw a more low-key version of this played out in our own federal election.Voters turned their backs on the two traditional parties in favour of the so-called 'micros', many of whom are underpinned by deep conservatism. One Nation's re-emergence from the political grave is perhaps the most potent example of this, but the more gentle, centrist populism offered by Nick Xenophon and his team was also embraced. The Coalition government, re-elected with the barest possible majority, seems endlessly beholden to the views of its right-wing faction. Time and time again, we have seen the conservative flank of the Liberal—National Coalition flex its political muscles, from the never-ending debate over section 18C of the _Racial Discrimination Act_ (the bit making it illegal to intimidate or offend someone on the basis of their race) to the eventual abandonment of the same-sex marriage plebiscite, when many argued it was a waste of money and should simply be put into law, given that most Australians support the notion.

But the debate that is most relevant here is the vituperative slanging match that emerged over the Safe Schools Coalition and the sexuality education program it offers to Australian schools. At its heart, Safe Schools is a program designed to help LGBTI kids feel secure at school. Coming out is still very difficult for many adolescents, and LGBTI young people have distressingly high rates of suicide. It's been reported by the mental health organisation beyondblue that same-sex-attracted Australians have a rate of attempted suicide that is 14 times higher than their heterosexual peers, and the age of the first suicide attempt is typically 16—often before they come out. This is a very serious matter, and Safe Schools was designed to ease the anguish and bullying some of these students face.

For transgender kids, the need to provide a safe and supportive school environment is even more pressing. Certainly, a great deal of attention has been given to young people who feel as though they were assigned the wrong gender at birth (gender dysphoria), and who can go through a great deal of anguish because of it. Associate Professor Michelle Telfer is head of adolescent medicine at Melbourne's Royal Children's Hospital (RCH), and she has spent much of her professional life working with children with gender dysphoria, and their families. Telfer says there is no question that more and more children are presenting to the RCH for treatment or guidance on this issue, a trend she puts down more to growing awareness and acceptance than any rise in incidence. The figures are quite striking: in 2012, for example, the hospital received 18 new gender dysphoria patients; in 2016, the number was 226. Telfer says that hospitals everywhere that treat children with gender dysphoria have had the same experience.

No-one knows why some kids feel as though they are girls when they were assigned 'boy' at birth, or vice versa. Many also argue that the idea of two genders, male and female, is far too restrictive. Instead, they talk of 'gender fluidity', which is the idea that gender, like sexuality, exists in diaspora rather than in binary. Where gender dysphoria is concerned, Telfer says there is probably a genetic link, but the nature of this is not yet known. Children concerned usually have a completely normal hormonal make-up.

Many children who seek help for gender dysphoria will take it no further—they will receive guidance, consider their options, and decide against treatment. However, Telfer estimates that at the RCH, about two-thirds of patients go on to treatment. Sometimes, young people on the cusp of adolescence, and who are highly distressed at the thought of going through puberty and the changes it will bring with it, can be prescribed puberty blockers—a temporary halt to development while they undergo the arduous legal process of applying to the courts for hormonal treatment to transition, or perhaps decide not to go ahead. Nothing is done lightly, nor without the young person and their family consulting a range of medical professionals.

In any case, here is the really important point: transgender kids, or those with gender questioning or dysphoria, are at great risk of suicide: Telfer says that in her experience, about 30 per cent of those not getting help are suicidal, and 30–50 per cent of those she sees in her practice have a history of self-harm.

Safe Schools provides important support for these young people in particular, as well as giving others greater understanding of the issue, including what some of their classmates might be going through. But the debate about the program has been hijacked by ideological interests. Conservative parliamentarians such as former Liberal senator Cory Bernardi (who recently formed his own party, the Australian Conservatives) and Queensland backbencher George Christensen are among its most outspoken critics, with Christensen likening the program to the grooming undertaken by sexual predators. They have found, as is so often the case, supportive friends in certain sections of the media, who have published a number of stories with screaming headlines.

As my friend and fellow journalist Gay Alcorn points out in her excellent analysis of the Safe Schools debate for _Guardian Australia_ , there are some questions for the Safe Schools Coalition in all this as well. Perhaps the publicity war could have been waged with a little more finesse; perhaps the case for the program could have been put a little more clearly and calmly. Still, the most salient point is that Safe Schools is designed to save the lives of a group of young people known to be at very high risk of suicide and self-harm, and for that it should be applauded and supported.

While current Victorian Premier Daniel Andrews—whose government has been progressive and proactive on LGBTI issues—argued strongly in favour of Safe Schools, Prime Minister Malcolm Turnbull, under pressure from the loud, sometimes hysterical right wing of his party, buckled at the knees. He ordered a review of the $8 million program, to be led by William Louden, emeritus professor of education at the University of Western Australia. In his subsequent report, Louden found little to frighten the horses; most of the concerns he outlined were around the age-appropriateness of specific material within the program. Louden concluded that the resources were consistent with the program's aims and objectives in reducing prejudice in terms of LGBTI students and gender diversity in schools. He also found that the key resource, _All of Us,_ was educationally sound. Even where there were activities that might not always be deemed appropriate, he wrote, 'their suitability falls within the reasonable range of teacher judgment'.

Not that any of these calm findings have deterred those who are so stridently against Safe Schools, of course. The program's controversial co-founder, La Trobe University academic Roz Ward, is no longer heading it, as La Trobe is no longer overseeing its implementation. There were concerns that the gender theory in the program was not suitable for schoolchildren, and worries about Ward's Marxist politics. Victoria's education department has now taken charge of the rollout of the program in every state secondary school by 2018 (it will also be available to primary schools and non-government schools). Meanwhile, New South Wales has moved to axe Safe Schools and replace it with a new anti-bullying program.

It is at least heartening that the program has not been axed altogether. But you can be sure that this will not be the last we hear of the matter, especially with the right wing of the Coalition federal government feeling the wind in its sails right now.

Like most political tides, this one will eventually go out to sea. Other ideas will come to the fore; events will happen that will change people's minds. The changes we are seeing in pubertal development, on the other hand, are unlikely to reverse anytime soon. It is important to keep pushing on this issue, to demand that governments take it seriously, that they look at the evidence and listen to the experts rather than being spooked by ideological fashion or ignoring it in the hope that it will go away.
Chapter 14

**Mandatory Sexuality Education: the Right to Know**

SCHOOLS AND TEACHERS are asked to do a great deal these days. We hear time and time again that our educational standards are at best stagnating, and at worst slipping behind comparable countries, especially in vital pedagogical and economic areas such as maths and science. But the pressure on schools isn't just limited to teaching kids to read and write. We look to schools for that perhaps slightly quaint notion of a broad, liberal education: in short, we ask them to help us create responsible, compassionate, well-informed and productive members of society. We ask them to teach kids about stranger danger, how to share, how to listen and be respectful. We ask them to show young people the world beyond their front doors, and to recognise and appreciate difference.

And sometimes—though nowhere near often enough or at a young-enough age—schools are also asked to teach children about puberty and sex. While we might like to say that this is the sole domain of parents, we all know that parents may or may not do it, and that even those who attempt it may not do it well, or with high-quality, age-appropriate information at hand. I can appreciate, from a principal's point of view, how tempting it might be to take that approach—to leave it to the parents, taking it off the teachers' overfull plates. But that never has, and never will, work. Schools are the best places to teach kids about puberty and sex, and it is crucial that they do it, and do it well, with government support.

It is also important that sexuality education is mandated and uniform. At the moment, it is all over the place. Schools are more or less free to do what they want, particularly at the primary level where the most urgent reform is needed. The national curriculum, which lays down what students should learn in each year of their schooling, stipulates that education about puberty (specifically) should take place at years 5 and 6. As I wrote earlier, originally puberty was slated for years 3 and 4, where the timing would have been much more in line with what we know about children and their development, but an outcry from Catholic schools saw it pushed back.

A further complicating factor is that government schools, which are run (and largely funded) by state governments, embrace the national curriculum at varying speeds. So as far as sexuality education is concerned, this means that public schools in Victoria, New South Wales and South Australia, for example, are required to teach it, while in Queensland and Western Australia, they can choose not to. (One of the experts in this area I spoke to says she believes that schools anywhere in the country can get away with not teaching it if they want to.) So some Australian children are receiving excellent sexuality education, and others are receiving none, or next to none. Imagine if the same were true of English or maths.

We in Australia are way behind on this. In England, which also has a conservative government, sexuality education has recently been mandated for all children at the primary and secondary levels. Under the new guidelines, schools will still have some flexibility in how the subject is taught, and parents will retain the right to withdraw their children from it. But nonetheless, the key issue is being addressed. As Education Secretary Justine Greening told the BBC, the government had to make the move because the previous curriculum was outdated, and so sexuality education was patchy: 'It's not mandatory, and, therefore, for many children, they are not coming out of our schools really being equipped to deal with the modern world or indeed be safe and protected from some of the very modern challenges that young people face on cyberbullying and sexting'. Indeed.

One of the most significant indicators of the trepidation with which this subject is handled in Australia is that, as I touched on in the previous chapter, teachers are being given inadequate training. Several principals I spoke with point this out. It is also borne out by research. A national survey of nearly 300 secondary teachers by La Trobe University in 2010 found that 16 per cent of those who were teaching sexuality education—most were health and physical education teachers—had no training at all in the subject. And those who had been trained had often had just one in-service session. Can you imagine standing in front of a class of adolescents, talking about changes in their bodies and sexuality, with little or no training in how to do it? Imagine trying to teach maths with no training, or French? We would all be horrified by such a thing, and we should be horrified by this.

There were other interesting revelations in the La Trobe study. For one thing, just under half the teachers surveyed said they were careful about what they taught in this subject area because they were worried about getting into trouble with parents or other community members. In other words, they self-censored, whether they needed to or not. How could that possibly be conducive to good learning? Most teachers also said they needed help with at least some of the topics they were expected to cover. And like the students in other surveys, they felt that many aspects of sexuality education were being taught too late. Again, imagine if this survey was about English rather than sexuality education—people would be outraged, and rightly so. Sexuality education is an important part of young people's learning, and it's absurd and wrong that it is taken so lightly.

The La Trobe survey is not the only research that has found sexuality education teachers struggling with inadequate training and knowledge. A study by Federation University Australia found much the same thing. In a survey of 29 years 5 and 6 teachers from the Ballarat region of Victoria, researchers found a huge gap between what teachers thought was important to teach in terms of sexuality education, and their ability to do so in terms of their own knowledge. For example, when asked about teaching puberty, the teachers said that menstruation and wet dreams were a source of anxiety—over 95 per cent agreed it was relevant to teach these topics, but at the same time they reported low confidence levels in doing so. Just under half the female teachers said they did not feel confident teaching about wet dreams; of the male teachers, 83 per cent did not feel confident teaching about menstruation.

It is, of course, difficult to teach something that is both sensitive and of which you have no personal experience. But it raises another salient point, again made clear by the La Trobe study: two-thirds of sexuality education teachers in their survey were female. It's a subject area that has traditionally been handed to female teachers, or for which they have volunteered, and that is not a healthy balance. It's important that men teach sexuality education in roughly the same numbers as women—not only because it's unhelpful for sexuality education to be ghettoised as a 'female subject', but also because students benefit the most from having someone who has not just read the textbook they're reading but who has actually gone through the same issues they are going through. Boys in particular need to hear from men they trust and respect on the subject.

There's no question that all of this is tricky. That's why so many schools opt to outsource their sexuality education, which in turn is why better teacher training is essential. Teachers being thrust into subjects outside their expertise, whether willingly or not, has gone on for years in maths and science, and our standards and engagement in both subjects seem to be in an inexorable slide. I started reporting on this 16 years ago as a schools reporter for _The Age_ and nothing much has changed in that time.

Primary-school teachers still feel anxious about teaching maths and science because they are not well versed in it themselves; perhaps they were never properly taught in the first place. This means that by the time they undertake their teaching degrees, they have long since—no doubt with some relief—dropped these subjects, hoping never to hear about them again. But they then find themselves having to inspire a class of bright and curious primary kids, and they lack the confidence to do so. (How the hell do you do fractions again?) As a result, the kids are not well taught, they come to dislike the subjects, and around the cycle goes.

Sexuality education is no different. How do we break this cycle? We start by training teachers to a high level and giving them the confidence and resources to teach well.

Opinion among educators is divided about whether sexuality education is best done by classroom teachers or outsourced to professionals in the area. One of the leaders in the field of sexuality education, and the author of several excellent sexuality education programs, former academic Jenny Walsh, is firmly of the opinion that it should be taught within schools. She reasons—and I agree with her—that classroom teachers in primary school have a special, close relationship with their students, which is handy because questions about puberty and sexuality can come up at any time.

Walsh, who has worked closely with, and trained, many people on teaching sexuality education, puts it like this:

Most parents have grown up not getting sexuality education themselves, so they don't know how to explain it to their kids. Teachers are the same, and they believe that they may do real damage. They don't want to harm the children and they don't want to get into trouble with the parents.

Another educator I spoke to, Gabrielle Leigh, is more agnostic about who should teach the subject. When she was a primary principal, she always outsourced sexuality education. She found it helpful to relieve the teachers of that particular burden—although the teachers sat in on sexuality education classes to hear what was being taught—and to ensure it was done properly. Again, though, it comes back to training.

An interesting case in point here comes from a primary school in a well-heeled inner-Melbourne suburb. This particular school is known to be progressive, servicing a community that combines affluence with a slightly alternative vibe. Its principal tells me that the school once outsourced its sexuality education but found the externally devised program to be inflexible, as it failed to acknowledge the diversity of the families that make up the school community. For example, there are several children who have two mums, and lesbian relationships were not acknowledged in the outsourced curriculum. The principal was constantly mindful that 'with just one word you can give a child a bad experience'. So the school designed its own sexuality education program with the help of Jenny Walsh. It now runs from Prep (the first year of primary school) through to Year 6—the principal, who was an assistant principal at the time, oversaw the program's design and implementation.

In Prep and years 1 and 2 (the school has multi-age classes), there are just four lessons in the program, in which the teachers talk about body parts, what people look like, and family diversity. They also talk about how a baby develops, but they try not to talk about how a baby is conceived until years 3 or 4, when the children are better equipped to understand. At the youngest level, these classes are taught by classroom teachers; after that, the school pays a specialist teacher to run the classes with the older children. The principal allows for that teacher in her budget because she thinks it's important to have consistency in what the students are taught.

Before the classes start, the school holds information sessions for parents, to let them know what their children are being taught. Mostly parents are supportive, but there are always some who are uncomfortable. The principal's response is a pragmatic one: 'We know the children are getting information. Often that information is wrong and potentially damaging. We are aiming to correct that'. Once the parents realise that their Prep kids are not being told about intercourse, their concerns are usually allayed.

The program has been running for about 10 years now and it hasn't been blemish-free—the principal has had to adapt it as it's gone along. The most notable example, she says, was a complaint made by parents with a strong Christian faith about material the Prep to Year 2 classes dealt with that looked at gender stereotypes before moving on to the idea of transgenderism. The principal thought about it, realised the parents had a fair point—the material was perhaps a bit beyond such young children—and made sure the curriculum was clear and consistent on this issue. Despite such hiccups, however, she considers the program to be a great success. It certainly holds up as a good example of flexibility and adaptation, which is exactly how it ought to be done.

Another important issue here is the context in which children are growing up these days and being educated. As we have discussed, talking to children about their development in Year 6 is way too late for most of them. It's no good telling girls about breast buds when they're already wearing a bra, or their period when they've already been startled by blood in their knickers. And there's little comfort for boys in hearing about wet dreams or unwanted erections long after they've had to learn to cope with them. Calm, clear, age-appropriate information right from the start of a child's schooling is the most sensible, practical and useful way to go.

It's not as though they won't hear about it elsewhere, and then god knows what they'll take in or understand. You only have to watch a three-year-old's dexterity with an iPad or iPhone to know how quickly children take to technology, how proficient they are with it, and yes, how effective a babysitter it is at times. We cannot supervise what they are watching every minute of the day (there's only so much _Peppa Pig_ we can reasonably be expected to endure). Nor can we be party to every conversation they have with their friends, or their friends' older siblings.

Many parents worry about the preponderance of pornography on the internet, and how easily their children might come across it. We know how familiar young people are with the online world, and we also know how easy it is to access pornography there, whether by accident or design. So it is perfectly reasonable for parents to be concerned about this, especially when so much porn is violent and misogynist. But I am also aware of how easily that word triggers a moral panic. Pornography, of course, is not new, but the ease of access to it that the internet provides still is. It's one of those sleeper issues that appears at the forefront of public debate every now and then, but no-one knows quite what to do with it, so it peters out. Mostly, I suspect, it's an issue that is the subject of concerned conversation between parents as they try to figure out if they need to worry, and if so, what they ought to do about it.

Sometimes that worry reaches the ears of our politicians. In December 2016, the Australian Senate published a report on its inquiry into the harmful effects of pornography on children through the internet. In it, the committee notes University of Wollongong academic Michael Flood's argument that while there is no good longitudinal evidence of an increase in rates of exposure of young people to pornography, the trends are likely to follow that of the United States, which has shown a significant increase in unwanted exposure. Research often reports that the average age of first exposure is now 12 years.

A 2016 survey of over 1000 Victorians aged 15–29 by the Melbourne-based Burnet Institute found that 89 per cent had intentionally watched pornography. But more interesting was the follow-up question, which asked the respondents how the pornography had affected them. Some responses were negative, some neutral and some positive (including that it had helped someone in 'understanding my own sexuality and body'). The point is that exposure to porn is not in itself a reason to throw up our hands: we need to give young people credit for being able to view it for what it is. And while I accept that not everyone will be able to do this, I do think that there's little point in getting hysterical about it.

Let's be realistic about this. We're not going to get rid of porn, nor is it necessarily a good idea to do so. Nor are we going to stop young people from accessing it, either before they are ready or before we think they are ready. Of concern to many people in this debate is the idea that pornography might be a young person's introduction to sex and sexuality. So the question is: Why on earth is that their introduction to it, and how have we failed them so completely in sexuality education that that's where they're getting their information from? Surely high-quality sexuality education would be the perfect buffer to any potential harm that premature exposure to porn might threaten.

The Senate report acknowledges as much. It quotes the Burnet Institute's submission in saying 'if our young people are looking primarily to pornography for their understanding of sex and sexuality, what does this say about the quality and relevance of our formal sexuality education?'. Tellingly, however, sexuality education did not appear in any of the four recommendations put forward by the committee, which included further research into children's exposure to pornography. However, it does suggest that policy measures could stem from that research, so perhaps there is hope yet.

Primary-school students are, anecdotally at least, already showing some confusion around the behaviour they see (whether they're just seeing pornography somewhere or if it's just from broader pop culture, or the adults around them, is not clear). There have been recent reports that teachers are increasingly seeing 'sexualised' behaviour by young children. In 2014, the ABC reported on Freedom of Information data they had obtained pointing to at least 940 reports of serious sexual assaults among schoolchildren in 2013. Sexual assaults are obviously a serious matter and need to be dealt with accordingly. But many of the principals I spoke to were talking about kids mimicking sexualised behaviour they had seen, and the effect that might have on them and the children around them.

The principal of the inner-Melbourne primary school I mentioned earlier says that, in her experience, more children are seeing pornography, and that nine seems to be the crucial age for it. Parents, she says, often think that any concerns about exposure to pornography won't kick in until their kids are about 12, but she tells them they need to get serious about it earlier than that.

Again, the logical antidote to the risk of bad information is getting in first with good information. And by getting in first, again, I mean from the time children start primary school. If Julie Andrews taught us anything in _The Sound of Music_ —apart from how to requisition old drapes for play clothes—it's the value of starting from the very beginning, which is, as she pointed out, a very good place to start. The first year of primary school is the perfect time to start talking to children about their bodies and relationships, with the curriculum developing alongside them through the remaining primary years, then turning to sex, contraception and other more sophisticated ideas in secondary school.

Really, what do we think will happen if we tell kids—again, stressing that it should be in an age-appropriate way—about how their bodies work and how they will change as they go through puberty? Do we think it's somehow dirty and sinful to talk about it, some shame-based throwback to our own childhoods? Or do we think that as soon as we mention anything about sex, kids will get out there and give it a burl? That their hormones will be triggered and their heads will explode? And yet, at the same time, we fret about how much children seem to know already, and where they might be getting that information from. It's time to deal with this contradiction.

There is a further important point to make here: children have a right to know, and we do not have the right to keep that information from them.

Let's imagine for a moment that one of the novels the children in an English class are asked to read contains elements of violence. Or sex. Or bad language. If you, as a parent, don't want your child exposed to any of those things, should you be allowed to withdraw him or her from that English class?

Another example. Say you believe in creationism and your child's science class is talking evolution, complete with those walking diagrams of our backs slowly straightening and our knuckles slowly lifting off the ground as we march boldly through history. Should you be allowed to withdraw your child from that class?

My immediate answer to these questions is 'No'. And I take the same position with sexuality education—which is a position the federal government disagrees with. In his written response to the Louden review of the Safe Schools program, which I described in the previous chapter, Education Minister Simon Birmingham said: 'Parents should have confidence in what is taught in a school and receive clear information, especially about potentially contentious issues. Parents should have the right to withdraw their child from classes dealing with such matters'.

Of course, this is the easiest path for governments to take (and the current federal government is far from alone here). In this climate of severe allergic reactions to adverse publicity, the idea of tossing a potentially incendiary issue back into the laps of parents in the name of 'free choice' is a very tempting one. But it is the wrong one.

The role of a school is to equip young people for a productive and happy life. There are a lot of specifics encased in those ideals, but that's the fundamental idea. To achieve this, expert educators work on a curriculum to ensure that those skills we believe to be important to a good life—reading, writing, numeracy, the ability to make friends and work with others—are embedded in children's learning. So just as we wouldn't allow children to be withdrawn from English or maths classes, nor should parents be able to withdraw them from sexuality education. The information that is (or at least ought to be) conveyed to students in these classes is vital for their wellbeing and understanding of the world they will grow up into and shape. And, let's face it, it's a hell of a lot more practical and important than some of the other things they will learn during their schooling.

If parents wish to present their children with a counterview to what is taught in schools—assuming schools are sticking to fact-based, proven information—they are of course free to do so. But to withhold information from students in the misguided belief that if they don't know about it, they won't engage in it, is muddle-headed.

There is an interesting parallel here in the controversies that routinely flare up around the teaching of religious education in government schools. One important point concerns the difference between educating and proselytising—or in the case of sexuality education, informing and encouraging particular behaviour. In government schools (as opposed to independent schools, which can do what they like regarding religion, as that's what parents agree to when they sign their kids up), the motto has always been 'free, secular, compulsory'. Free more or less went out the window some time ago, but secular and compulsory have remained, and rightly so.

In Victoria, debate raged for years over the role of Access Ministries in teaching special religious instruction (SRI) in government schools, including accusations of proselytising. In 2015, the Andrews government finally scrapped SRI from standard class time, replacing it with new teaching on history, cultures, faiths and ethics. What theVictorian Government was emphasising here was the difference between teaching young people about the world and encouraging them to behave in a certain way, and telling them to adopt certain beliefs. I have no particular religious beliefs, but I think it is right that children should learn about religion—all kinds, not just Christianity—because it has played such a vital role in the history of so many countries and continues to be pivotal today. In other words, it is fundamental work for a school to do.

Sexuality education is no different. Young people need to receive accurate, age-appropriate information on puberty, sex, relationships and reproduction. These are fundamental aspects of life, central to our experience as human beings. This is not the same as encouraging kids to go out and have sex—as far as I know, no school is doing that. So why on earth wouldn't we teach it?

And it's not just about giving young people clear, accurate information with which they can pass tests on the subject in question. Rather, the knowledge they gain in high-quality sexuality education classes will stay with them throughout their lives. It has the potential to guide them towards safe, healthy actions and avoid a lot of grief.

One of the areas that would be addressed by better sexuality education is the prevalence of sexually transmitted infections (STIs), which is high among young Australians. While the incidence of human immunodeficiency virus (HIV) has remained relatively stable in recent years, other diseases have a patchier record. Notifications of gonorrhoea, for example, nearly doubled in both men and women between 2006 and 2015. And while the level of chlamydia among 15–19-year-olds has actually declined since 2011, it nonetheless remains high; in fact, like gonorrhoea, it is most prevalent among people aged 20–29.

Young people do not know enough about these diseases. In 2013, the fifth in a series of four-yearly surveys of secondary students' sexual health by Melbourne's La Trobe University found that while knowledge of HIV was relatively good, STI knowledge was poor. This was despite the fact that 69 per cent of the students in years 10, 11 and 12 had engaged in some form of sexual activity, and 34 per cent had had intercourse. In the same survey, one in 10 students reported having had no sexuality education at school. How much better might these figures have been if all those surveyed had been given age-appropriate sexuality education by well-trained teachers in primary school?

Few people would argue about the value of good education, yet still we wriggle and squirm on sexuality education. Sometimes, education is uncomfortable. Sometimes, it challenges our world view, blows up our long-held beliefs, makes us question our assumptions, exposes our hypocrisy and our ignorance. That's how we know it's worthwhile. We want our children to learn these lessons so that they grow into well-informed, thoughtful, compassionate members of society, because we know that this is the key to a happy and productive life.
Chapter 15

**Let's Make It Happen (and Make It Good)**

IT'S TEMPTING TO think of the adolescent as some kind of unnerving (if not terrifying) beast; a strange, monosyllabic and surly presence that only lights up when scrolling through social media posts or engaging with friends. Few of us would be surprised if a second head emerged from the side of their neck at some point, dedicated to eye-rolling, or their texting got so furious that they blew a gasket, their faces peeling down to reveal only dodgy mechanics and unregulated emotion (note to self for movie script).

We dread The Teenager so much because we were once in their shoes, and we know what a shitty time of life that can be: the desperate need to fit in, the anxiety about who likes them and who doesn't, the potential bullying, body image anxiety, exclusion and confusion, the search for understanding and what makes them special and happy. Meanwhile, their bodies seem to take on a weird life of their own, all long limbs and oily skin, with boobs and hair sprouting out of nowhere. And that's just how it is in a run-of-the-mill adolescent. Now add real adult stresses such as family violence, alcohol abuse, separation or divorce, disability, gambling, drug abuse or mental health problems, and the stress goes to another level. And unlike my generation, kids nowadays must contend with social media and all its delights and miseries. Honestly, I wouldn't be a teenager again for anything. Soz, kids.

Having said that, adolescence doesn't have to be the stressful, combative time that we parents dread; puberty doesn't need to be something you just have to 'get through'. This can be the time to develop a more meaningful relationship with your son or daughter (or whoever the young people in your life might be) which reflects their journey from child to adult, and to negotiate how that might work between you.

To me, all of this starts with the first signs of puberty, and that now often means primary school. We know that, as a nation, we are getting taller and fatter: this is no longer breaking news. But there is now good evidence that this in turn is having a significant impact on the onset of puberty (perhaps in combination with other environmental impacts), with at least some children starting pubertal development earlier than has happened before.

The world in which children and adolescents are growing up in is also increasingly complex, fascinating, and full of potential and risk. We live in a 24-hour news cycle in the middle of a technological revolution. We connect with each other more than ever, but not necessarily in constructive ways, particularly for the young. The online world can be intriguing, informative, witty as hell and delightfully littered with cats doing amusing things. But it can also be hostile, aggressive, violent, frightening, threatening, false, misleading and depressing. This is not easy for an adult to navigate, much less a child.

Like so many other aspects of our lives, parenting has arguably never been as closely scrutinised, fretted over and commodified as it is these days. You only need to read through a book outlining how to care for a baby or toddler to find yourself beset with insecurities about your own parenting, and worries that your child is not quite right. Is she reaching her milestones? Why isn't he talking yet? Is she keeping up with Jasper and Arlo and Clementine? Is there a more anxious group in society than parents? I doubt it. Nevertheless, today, children need information earlier than ever. Unfortunately, they have plenty of access to the wrong kind. The obvious antidote to this is to provide the right information, and from an early age.

Puberty has long been a neglected area of research and, frankly, of conversation and public interest. It's time that changed. Here are some practical measures that will help achieve that.

We need better, and more, longitudinal research into puberty, its variations, the changes it brings over time, and its relationships with other aspects of health and wellbeing such as diet, exercise, family situation and mental health. We also need to look at how it is affected by race and ethnicity, genetics and culture.

The at times farcical debate around the Safe Schools program reminds us just how incendiary this issue is, but of course we can't let that worry us. We must put pressure on governments to implement age-appropriate and compulsory sexuality education from at least middle primary school, if not from the start of primary school. This means—and this bit is important—it would need to be a specifically funded program, so that principals are not having to scratch around in their budgets to find the money for it.

We must improve the training of teachers on sexuality education, before they are asked to take charge of a class. It is unfair to both teachers and students to have poorly trained individuals who are anxious about saying the wrong thing, or about blowback from parents, standing in front of a primary-school class. Additionally, we need to encourage male teachers as well as female teachers to be trained in this area: it's important that both genders are represented in this, so that it doesn't become a 'female' issue. It is also vital to have role-modelling and to give students the opportunity to ask questions or extend conversations beyond the confines of allocated lessons.

This is the final point, but in many ways it should be the foremost: we need to talk about puberty, about changing bodies and changing brains. We must overcome our discomfort and embarrassment about this, because that's the only way we'll be able to stop our children from feeling the same way. We must have a frank and open discussion about it among ourselves as adults, so that we can have a frank and open discussion about it with our kids. Be proactive about talking to kids about puberty, and read up on the subject before you do so that you feel confident in what you say. It's OK to feel a bit embarrassed about it, and far better to admit that than to let it silence you. We need to shake off the quaint idea that informing children about relationships and their bodies somehow 'robs' them of childhood, because this is absurd—no amount of accurate, age-appropriate information will inhibit a game of 'chasey'. Lastly, don't forget to ask your child's school, especially if it's a primary school, about how sexuality education is taught there, when, and by whom; and if you are unhappy about any of this, speak to a teacher or the principal.

We have been talking about reforming sexuality education for years, but nothing much ever happens. We have taken so much time over this, in fact, that right under our noses, adolescence in general and puberty in particular have changed. Now we need to act. We need to put pressure on our political leaders to bring about real, immediate and funded change, to stop being scared of upsetting interest groups that do not represent most Australians or, more importantly, our children's best interests.

We cannot keep hiding from this. Our children need us to be the grown-ups now.
**Acknowledgements**

Such is the nature of puberty and sexual development that it taps into some of the most private aspects of our lives. It is also an area with no small degree of sensitivity, so to that end, the names of some of the people who have related their personal experiences of puberty have been changed, as have the names of school principals and teachers. All the medical specialists are quoted under their real names.

In researching this book, I spoke with dozens of specialist doctors, psychologists, social researchers, principals, teachers and parents, all of whom were extremely generous with their time and expertise, and without whom this project could not have been completed. Among them were some who went far above and beyond the call of duty.

I'm first and foremost indebted to George Patton and Susan Sawyer, whose work on adolescence I have followed and reported on for years, and who made me interested in the changing nature of puberty in the first place. They both also gave valuable feedback on early drafts. Susan was good enough to use a long-haul flight to read and annotate the entire book, for which I am eternally grateful.

Despite being extremely busy specialist doctors, Phil Bergman, Charlotte Elder and Cecilia Garcia Rudaz were generous and patient with their expertise, checking facts and explaining some of the complex science around puberty. I am grateful to Kate Stern in so many ways, including the help she gave on gynaecological issues in the book. Lisa Mundy has been a kind and supportive source of information, particularly on CATS research, while Michelle Jack, Michelle Telfer, Jo-Ann See and Samantha Eisman all gave and checked information in their specialist areas.

Michael Carr-Gregg and Andrew Fuller made time for multiple interviews on the psychological and emotional aspects of adolescence and provided excellent advice for parents that is included in the book. Carla Pascoe, Elise Holland and Lauren Rosewarne were terrific at helping fill out the broader social and cultural questions.

Jenny Walsh, Gabrielle Leigh and several principals and teachers were generous with their intimate knowledge of sexuality education in Australian schools.

I couldn't ask for better publishers than the wonderful team at MUP: Louise Adler was supportive and kind from the start, while Paul Smitz, Cathy Smith and Tessa Connelly have been terrific in making the best possible book. Sally Heath was my friend long before she was my fabulous editor, and I'm pleased to say she's still both at the end of it.

My colleagues at The Conversation, while no doubt glad the book is finished, have been very supportive in the writing of it, for which I am extremely grateful.

I am fortunate to have a number of journalist friends who gave terrific feedback on early drafts, and encouragement all the way through: Gay Alcorn, Paul Austin, Michael Bachelard, Shaun Carney, Shane Green, Fron Jackson-Webb, Michael Lallo and Thornton McCamish have my heartfelt thanks.

It would be impossible to write a book while raising a small child without having a lot of practical support, too. In that respect I am extremely grateful to my mum, Jenny Pepper, for the unfailing support and love she has given us. We were also lucky enough to have people like Anita and Daniel Bennell, Helen Shinkfield, Jon Dunn and Lyn Hoare in our corner.

Finally, my greatest thanks goes to my daughter Molly, who makes anything possible, and everything better.
**Notes**

 1 Australian Bureau of Statistics, 2007, 'Lifetime marriage and divorce trends', <http://www.abs.gov.au/ausstats/abs@.nsf/0/26D94B4C9A4769E6CA25732C00207644?opendocument#TRENDS%20IN%20MARRIAGE%20AND%20DIVORCE>

 2 Australian Bureau of Statistics, 2016, 'Brides, grooms and divorcees have never been older', <http://www.abs.gov.au/ausstats/abs@.nsf/products/118F4A846EEB21F8CA2576200025DF55?OpenDocument>

 3 Australian Bureau of Statistics, 2017, 'Births, Australia, 2015', <http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3301.0Main+Features32015?OpenDocument>

 4 Figures provided to the author by Australian Institute of Family Studies.

 5 Australian Institute of Family Studies, 2016, 'The Longitudinal Study of Australian Children: Annual statistical report 2015', <http://www.growingupinaustralia.gov.au/pubs/asr/2015/asr2015.pdf>

 6 beyondblue, 2017, 'Stats and facts', <https://www.youthbeyondblue.com/footer/stats-and-facts>

 7 Data provided to the author.

 8 Emans, S Jean et al., 2005, _Pediatric & Adolescent Gynecology,_ 5th edn, Lippincott, Williams & Wilkins, pp. 120–4.

 9 If you're interested in learning more about this, a quick google of 'Tanner scale' will do the trick. Despite being over 40 years old, it is still commonly cited in medical literature today and used as the basis for research into pubertal development. Also see Marshall, WA and Tanner JM, 1969, 'Variations in Pattern of Pubertal Changes in Girls', Archives of Disease in Childhood, 44, 291, and Marshall, WA and Tanner, JM, 1970, 'Variations in Pattern of Pubertal Changes in Boys', Archives of Disease in Childhood, 45, 13.

 Herman-Giddens, Marcia E et al., 2012, 'Secondary sexual characteristics in boys: Data from the Pediatric Research in Office Settings Network', _Pediatrics,_ October.

 For some of the best, most interesting and global perspectives on changes to adolescence, take a look at 'Our future: A Lancet commission on adolescent health and wellbeing' ( _The Lancet_ , May 2016, <http://www.thelancet.com/commissions/adolescent-health-and-wellbeing>), from which these figures were taken.

 The history of menarche is explained in more detail in the two fascinating publications from which this information is drawn: Gluckman, Peter D & Hanson, Mark A, 2006, 'Evolution, development and timing of puberty', _Trends in Endocrinology and Metabolism,_ vol. 17, no. 1; and Hochberg, Ze'ev & Belsky, Jay, 2013, 'Evo-devo of human adolescence: Beyond disease models of early puberty', _BMC Medicine,_ vol. 11.

 Australian Bureau of Statistics, 2013, 'Profiles of Health, Australia, 2011–13: Overweight and Obesity', <http://www.abs.gov.au/ausstats/abs@nsf/Lookup/by%20Subject/4338.0~2011–13~Main%20Features~Overweight%20and%20obesity~10007>

 Australian Bureau of Statistics data quoted in Lehmann, Megan, 2016, 'Taller, faster, sooner: Australia's growth spurt', _The Australian,_ 26 March.

 Australian Institute of Health and Welfare, 2017, 'Who is overweight?', <http://www.aihw.gov.au/who-is-overweight/>

 British neuroscientist Professor Sarah-Jayne Blakemore's work is fascinating and she's pulled it together in a highly readable book: Blakemore, Sarah-Jayne & Frith, Uta, 2011, _The Learning Brain: Lessons for Education,_ Blackwell Publishing.

 Deardorff, Julianna et al., 2011, 'Father absence, body mass index, and pubertal timing in girls: Differential effects by family income and ethnicity', _Journal of Adolescent Health,_ vol. 48, no. 5.

 Chisholm, James S et al., 2005, 'Early stress predicts age at menarche and first birth, adult attachment, and expected lifespan', _Human Nature,_ vol. 16, no. 3.

 Euling, Susan Y et al., 2008, 'Role of environmental factors in the timing of puberty', _Pediatrics,_ vol. 121, supp. 3.

 Williams, Florence, 2012, _Breasts: A Natural and Unnatural History,_ Text Publishing.

 Aksglaede, L et al., 2009, 'Recent decline in age at breast development: The Copenhagen study', _Pediatrics,_ vol. 123, no. 5.

 Biro, Frank M et al., 2012, 'Puberty in girls of the 21st century', _Journal of Pediatric and Adolescent Gynecology,_ October.

 Herman-Giddens, Marcia, 2013, 'The enigmatic pursuit of puberty in girls', _Pediatrics,_ vol. 132, no. 6.

 Knowles, Lorna & Branley, Alison, 2014, 'Data reveals allegations of children sexually abusing peers at school, experts call for action', ABC News online, 31 July.

 Dunn, Amanda, 2015, 'What's happening to me?', _The Sunday Age,_ 25 January.

 For more on this, and to watch the ads, visit the following website: <http://www.respect.gov.au>

 Australia's 39 universities have asked the Human Rights Commission to survey university students about their experiences of sexual assault and sexual harassment on campus. At the time of writing, the results were expected shortly. You can read more about the survey here: <https://www.humanrights.gov.au/our-work/sex-discrimination/projects/university-sexual-assault-and-sexual-harassment-project>

 Two excellent resources on all aspects of puberty are: Darvill, Wendy & Powell, Kelsey, 2010, _The Puberty Book,_ Hachette and Meredith, Susan, 2006, _What's happening to me?,_ Usborne.

 Sanghani, Radhika, 2014, 'Pubic hair: 8 things you need to know before you shave', _The Telegraph,_ 10 September.

 Tiggemann, Marika & Lewis, Christine, 2004, 'Attitudes toward women's body hair: Relationship with disgust sensitivity', _Psychology of Women Quarterly,_ December.

 See the Australasian Paediatric Endocrine Group website, specifically the ANZ growth chart for girls aged 2–18 years: <https://apeg.org.au/clinical-resources-links/growth-growth-charts>

 'Nepalese teenager dies after being banished to shed for menstruating', 2016, _The Guardian_ online, 21 December, https://www.theguardian.com/world/2016/dec/21/nepal-teenager-dies-banished-shed-menstruating

 See <http://www.helloclue.com> for more details on the survey.

 The Advertising Standards Bureau regularly publishes a list of the 'top 10'complaints. See, for example the 2015 list, which features ads about tampons and pads: <https://adstandards.com.au/media-releases/%E2%80%98inappropriate%E2%80%99-behaviours-fuel-ad-complaints>

 Rosewarne, Lauren, 2012, _Periods in Pop Culture,_ Lexington Books.

 Oh, how I love Tina. If you haven't read her memoir, it's worth doing so: Fey, Tina, 2011, _Bossypants,_ Little, Brown and Company.

 For more information, see this helpful resource: The Australasian Paediatric Endocrine Group, 2011, 'Hormones and me: Puberty and its problems', <https://apeg.org.au/patient-resources/hormones-me-booklet-series/>

 Centre for Genetics Education, 'Fact sheet 40:Turner Syndrome', <http://www.genetics.edu.au/Publications-and-Resources/fact-sheets/fact-sheet-40-turner-syndrome/>

 Emans, S Jean et al., 2005, _Pediatric and Adolescent Gynacology,_ 5th edn, Lippincott, Williams and Wilkins.

 The Royal Children's Hospital has some good resources on its website, including how to take the pill continuously; see <http://www.rch.org.au/kidsinfo/fact_sheets/Oral_Contraceptives_-_Skipping_periods_when_taking_the_Pill/>

 The Jean Hailes Foundation, which specialises in women's health, has several excellent resources on its website that clearly explain these conditions and the treatment options; see <https://www.jeanhailes.org.au>

 For more information, see Witchel, Selma F et al., 2015, 'The Diagnosis of polycystic ovary syndrome during adolescence', _Hormone Research in Paediatrics,_ vol. 83.

 The Jean Hailes website has a very clear and useful booklet about PCOS: <https://jeanhailes.org.au/contents/documents/Resources/Booklets/PCOS_All_you_need_to_know.pdf>

 Jongenelis, Michelle I et al., 2014, 'Self-objectification, body image disturbance, and eating disorder symptoms in young Australian children', _Body Image,_ vol. 11, no. 3, <http://research-repository.uwa.edu.au/en/publications/self-objectification-body-image-disturbance-and-eating-disorder-symptoms-in-young-australian-children(b36a3735-ae5f-4b22-a0b3-bb2c889916b0).html>

 For a good analysis of fitspo, see: Holland, Elise, 2016, 'Why the fitspo movement is damaging to women', The Conversation, 15 July, <https://theconversation.com/why-the-fitspo-movement-is-damaging-to-women-60453>

 See: Plan International Australia and Our Watch, 2016, 'Everyday sexism: Girls' and young women's views on gender inequality in Australia', October, <https://www.ourwatch.org.au/getmedia/1ee3e574-ce66–4acb-b8ef-186640c9d018/Everyday-Sexism_version_03.pdf.aspx>

 See the recommendations of the inquiry, and the government's response, here: <http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Environment_and_Communications/Completed_inquiries/2008–10/sexualisationofchildren/index>

 Hunt, Elle, 2016, 'Batgirl "housework": Target removes "sexist" T-shirt and apologises', _The Guardian_ online, 31 August, <https://www.theguardian.com/world/2016/aug/31/batgirl-housework-target-removes-sexist-t-shirt-and-apologises>

 Smink, Frederique RE et al., 2012, 'Epidemiology of eating disorders: Incidence, prevalence and mortality rates', _Current Psychiatry Reports,_ vol. 14.

 Patton, George C et al., 2008, 'Predicting female depression across puberty: A two-nation longitudinal study', _Journal of the American Academy of Child and Adolescent Psychiatry,_ vol. 47, no. 12.

 Rosenstreich, Gabi, 2013, 'LGBTI people: Mental health & suicide', briefing paper, revised 2nd edn, <https://www.beyondblue.org.au/docs/default-source/default-document-library/bw0258-lgbti-mental-health-and-suicide-2013–2nd-edition.pdf?sfvrsn=2>

 Australian Government, 2015, 'The mental health of children and adolescents: Report on the second Australian child and adolescent survey of mental health and wellbeing'.

 For more information, see: Carr-Gregg, Michael, 2015, _Strictly Parenting,_ Penguin.

 Herman-Giddens, Marcia E et al., 2012, 'Secondary sexual characteristics in boys: Data from the Pediatric Research in Office Settings Network', _Pediatrics,_ October.

 Nielsen, C Thoger et al., 1986, 'Onset of the release of spermatozoa (spermarche) in boys in relation to age, testicular growth, pubic hair and height', _Journal of Clinical Endocrinology & Metabolism,_ vol. 62, no. 3.

 Veale, David et al., 2015, 'Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in 15 521 men', _BJUI International,_ vol. 115.

 Lever, Janet et al., 2006, 'Does size matter? Men's and women's views on penis size across the lifespan', _Psychology of Men and Masculinity,_ vol. 7, no. 3, July.

 See the Australasian Paediatric Endocrine Group website, specifically the ANZ growth chart for boys aged 2–18 years: <https://apeg.org.au/clinical-resources-links/growth-growth-charts>

 The ABC science show _Catalyst_ has an interesting program on the subject: 'Teenage Acne', <http://www.abc.net.au/catalyst/stories/3608431.htm>

 Andrology Australia has an excellent information sheet about gynaecomastia; see <https://www.andrologyaustralia.org/gynaecomastia/>

 Again, see the Australasian Paediatric Endocrine Group website, specifically the ANZ growth chart for boys aged 2–18 years: <https://apeg.org.au/clinical-resources-links/growth-growth-charts/>

 Two of the best books on puberty written for young people that I have read are, firstly, an oldie but a goodie: Frith, Alex & Meredith, Susan, 2007, _What's Happening to Me?: Boys' Edition,_ Usborne; and secondly: Darvill, Wendy & Powell, Kelsey, 2010, _The Puberty Book,_ 5th edn, Hachette.

 The Australasian Paediatric Endocrine Group says girls are about 20 times more likely to go through puberty early than boys. APEG has produced a very useful booklet on this: The Australasian Paediatric Endocrine Group, 2011, 'Hormones and me: Puberty and its problems', <https://d192ha6kdpe15x.cloudfront.net/apeg/assets/uploads/2016/03/hormonesme5_pubertyits_problems.pdf>

 American Academy of Pediatrics, 2017, 'Delayed puberty in boys: Information for parents', <https://www.healthychildren.org/English/ages-stages/gradeschool/puberty/Pages/Delayed-Puberty.aspx>

 A very clear and good explanation of the genetics of Klinefelter's syndrome can be found here: <http://patient.info/health/klinefelters-syndrome-leaflet>

 Herlihy, Amy S et al., 2011, 'The prevalence and diagnosis rates of Klinefelter syndrome: An Australian comparison', _MJA,_ vol. 194, no. 1.

 Another good explanation of the condition can be found at Andrology Australia's website: <https://www.andrologyaustralia.org/wp-content/uploads/Factsheet-KlinefeltersSyndrome.pdf>

 Blakemore, Sarah-Jayne & Frith, Uta, 2005, _The Learning Brain: Lessons for Education,_ Blackwell Publishing.

 Blakemore, Sarah-Jayne et al., 2010, 'The role of puberty in the developing adolescent brain', _Human Brain Mapping,_ vol. 31, no. 6.

 McLachlan, Robert, 2014, 'Here's what you need to know about testosterone', The Conversation, 18 September.

 beyondblue, 2017, 'Stats and facts', <https://www.youthbeyondblue.com/footer/stats-and-facts>

 Black Dog Institute, 2017, 'Facts & figures about mental health', <https://www.blackdoginstitute.org.au/docs/default-source/factsheets/facts_figures.pdf?sfvrsn=8>

 For more on Mission Australia's annual youth survey, go to <http://www.missionaustralia.com.au/what-we-do/research-evaluation/youth-survey>

 Mensah, Fiona & Patton, George, 2013, 'Growing up too fast: Early puberty and mental illness', The Conversation, 3 April.

 This is an intriguing study; for the details, see: Peper, Jiska S et al., 2013, 'Development of risk taking: Contributions from adolescent testosterone and the orbito-frontal cortex', _Journal of Cognitive Neuroscience,_ July.

 For more on Andrew Fuller's view on these and other matters, see his books _Tricky Teens_ (2014, Finch Publishing) and _Unlocking Your Child's Genius_ (2015, Finch Publishing).

 For more information, see <http://www.resilientyouth.org.au/survey>

 See Wilson, Amanda, 2016, 'Looking for health advice? Don't consult health magazines, try _Dolly',_ The Conversation, 21 November, <https://theconversation.com/looking-for-health-advice-dont-consult-health-magazines-try-dolly-63823>

 Australian Bureau of Statistics, 2016, 'Household use of information technology, Australia, 2014–15', <http://www.abs.gov.au/ausstats/abs@.nsf/mf/8146.0>

 Duffy, Bernadette et al., 2012, '"It says sexual education but all it is, is just puberty": The perspectives of secondary school students on the timing of topics in sexuality education', Australian Association for Research in Education, <http://www.aare.edu.au/publications-database.php/6495/%E2%80%9CIt-says-sexual-education-but-all-it-is,-is-just-puberty%E2%80%9D-The-perspectives-of-secondary-school-students-on-the-timing-of-topics-in-sexuality-education->

 Rosenstreich, Gabi, 2013, 'LGBTI people: Mental health and suicide', National LGBTI Heath Alliance briefing paper, 2nd edn.

 Alcorn, Gay, 2016, 'The reality of Safe Schools', _The Guardian Australia,_ 13 December, <https://www.theguardian.com/australia-news/2016/dec/14/safe-schools-roz-ward-life-saving-support-queer-theory-classroom>

 Louden, William, 2016, 'Review of appropriateness and efficacy of the Safe Schools Coalition Australia Program resources', 11 March, <https://docs.education.gov.au/system/files/doc/other/review_of_appropriateness_and_efficacy_of_the_ssca_program_resources_0.pdf>

 For more information, see <http://www.education.vic.gov.au/about/programs/health/Pages/safe-schools-coalition.aspx?Redirect=1>

 Smith, Alexandra & Aston, Heath, 2017 'NSW Education Minister Rob Stokes to dump Safe Schools program', _The Sydney Morning Herald_ online, 17 April, <http://www.smh.com.au/national/education/nsw-education-minister-rob-stokes-to-dump-safe-schools-program-20170416-gvlp47.html?deviceType=text>

 For more information on the UK Government's move, see: <https://www.gov.uk/government/news/schools-to-teach-21st-century-relationships-and-sex-education>

 Sellgren, Katherine, 2017, 'Sex education to be compulsory in England's schools', BBC News online, 1 March, <http://www.bbc.com/news/education-39116783>

 Smith, Anthony et al., 2010, 'Sexuality education in Australian secondary schools: Results of the 1st National Survey of Australian Secondary Teachers of Sexuality Education 2010', Australian Research Centre in Sex, Health & Society, La Trobe University, April.

 Duffy, Bernadette et al., 2013, 'Puberty, health and sexual education in Australian regional primary schools: Year 5 and 6 teacher perspectives', _Sex Education,_ vol. 13, no. 2.

 The Senate Environment and Communications References Committee, 2016, 'Harm being done to Australian children through access to pornography on the internet', November, <http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Environment_and_Communications/Online_access_to_porn>

 Burnet Institute, 2016, 'Sex, Drugs and Rock 'n' Roll study', https://www.burnet.edu.au/projects/17_big_day_out _studies_sex_drugs_and_rock_n_roll

 Knowles, Lorna & Branley, Alison, 2014, 'Data reveals allegation of children sexually abusing peers at school, experts call for action', _ABC News_ online, 31 July.

 Senator the Hon Simon Birmingham, 2016, 'Statement on Safe Schools Coalition', media release, 18 March.

 Cook, Henrietta & Jacks, Timna, 2015, 'Religious instruction scrapped from curriculum', _The Age_ online, 21 August.

 Kirby Institute, University of New South Wales, 2016, 'HIV, viral hepatitis and sexually transmissible infections in Australia: Annual Surveillance Report'.

 Australian Research Centre in Sex, Health and Society, La Trobe University, 2014, 'National Survey of Australian Secondary Students and Sexual Health, 2013'.
**Index**

Access Ministries

acne 62–3, 123–4

active parenting 111–12

adenomyosis 90–1

adolescence

definition

protracted duration 8–10,

sexuality 106–7

adolescent health

adolescent stereotype

adrenarche , 45–7

adult ideas and images, children's exposure to , 36–7,

aggressive behaviour

Alcorn, Gay

amenorrhoea 83–4

Andrews, Daniel

androgens , 48–9,

anorexia nervosa 104–5,

anxiety , ,

aromatase

Bergman, Phil , , , , 126–7,131–2,132–3

Bernardi, Cory

Birmingham, Simon

Bisphenol A (BPA)

Blakemore, Sarah-Jayne

Blume, Judy

body fat, and onset of puberty

body image 95–101, 103–5,

body odour 124–5

bone growth

boys

adrenarche

age of onset of puberty , , 118–19

body image 96 'breaking' of voice ,

breast development 125–7

delayed puberty 117–18, , 132–4

facial hair

growth spurt 127–8

helping them be comfortable with their bodies 135–6

hormonal shifts and physical changes 18–19, 19–20

Klinefelter's syndrome , 134–5

mental health 142–3

odour 124–5

penis length 120–2

pimples and acne 123–4

precocious puberty 131–2

pubertal development , 119–29

pubic hair 122–3

risk-taking behaviour , 141–2

social and emotional development 137–45

spontaneous erections , 128–9

testicular volume 119–20

voice 'breaking' ,

wet dreams

brain development , 137–8

brain function, impact of androgens

breast cancer

breast development , , , , , 30–2, 60–1, 125–7

buried penis 121–2

Carr-Gregg, Michael , , , , ,

cervical mucus

childhood obesity

Childhood to Adolescence Transition Study (CATS) , , , , ,

children's sexuality

Chisholm, James

chlamydia

Christensen, George

communication

comprehensive sexuality education (CSE)

contraceptive pill 85–6,

Copenhagen Puberty Study

cytokines

delayed puberty , 81–3, 117–18, 130–1, 132–4

depression , ,

diet, and body image 99–100, 103–5

_Dolly_ magazine ,

'don't you look pretty' syndrome 95–6, ,

dysmenorrhoea 85–6

earlier puberty

eating disorders , 104–5

Elder, Charlotte , , ,

emotional changes, in adrenarche

endocrine disruptors ,

endometriosis 87–90

environmental toxins 28–9,

erections, spontaneous , 128–9

ethnicity, and onset of puberty ,

evolutionary adaptation, early onset of puberty as , 140–1

facial hair

family set-up, and onset of puberty

female fertility

female genitalia, terms for ,

female sexuality ,

femaleness

feminine hygiene products, marketing of , 74–6,

fertility , 89–90

Fey, Tina ,

fibroids

'fitspo' movement

Flood, Michael

follicle-stimulating hormone (FSH) , ,

food porn

Fuller, Andrew ,

gender dysphoria 156–8

girls

age of onset of puberty 11 body image 95–101

body shape

breast development , , , , , 30–2, 60–1

challenging behaviour

delayed puberty 81–3

growth spurt 64–5

helping them be comfortable with their bodies 93–4

hormonal shifts and physical changes ,

mental health 104–10

pimples and acne 62–3

precocious puberty 25–6, 80–1

preparing them for menarche 77–8

pubic hair 61–2,

sexualisation 41–2, 101–3, 105–6

sexuality 106–7

vaginal discharge 63–4

vulnerability 58–9

gonadal puberty

gonadarche ,

gonadotropin-releasing hormones (GnRH) , ,

gonorrhoea

growth spurt , 64–5, 127–8

guilt

gynaecomastia 126–7

health issues, and onset of puberty 2–3

heart disease

height 23–4

Herman-Giddens, Marcia 31–2

hirsutism

HIV (human immunodeficiency virus)

Hunt, Patricia

hypothalamic–pituitary–gonadal axis 18–19

impulse-control problems

infertility , 89–90

internet access , 168–9

irregular periods ,

Jack, Michelle

Kang, Melissa ,

Klinefelter's syndrome , 134–5

Kovacs, Gab

laparoscopy

Leigh, Gabrielle ,

LGBTI young people 106–8, , 156–9

Longitudinal Study of Australian Children (LSAC) 11–12, , ,

Louden, William

luteinising hormone (LH) ,

McLachlan, Robert

male genitalia, terms for

male–female sexuality

maleness ,

mammary glands 29–30

marriage age

masculinity ,

_Mean Girls_ (film)

menarche , 11–12, , 20–1, , ,

menopause

menorrhagia 86–7

menstrual cycle , 68–9

menstruation

biology of 66–7,

cultural attitudes towards 7–8, , 70–7

euphemisms for

heavy periods 86–7

irregular periods ,

no periods 83–4

pain 70–1, 85–6

teaching about

mental health , , 104–10, , 142–3

micropenis

middle primary years, development in 44–51

motherhood, age of

Mundy, Lisa

obesity , , , , ,

oestradiol

oestrogen , , , 125–6

orchidometers

osteoporosis

ovarian cysts

ovulation 68–9

parenting, scrutiny of

Pascoe, Carla 72–4

Patton, George 5–6, , ,

penis length 120–2

pimples 62–3, 123–4

polycystic ovary syndrome (PCOS) 91–3

pornography , , , , 168–71

Prader, Andrea

precocious puberty 25–6, 80–1, , 131–2

premenstrual syndrome (PMS) 69–70

primary amenorrhea 83–4

progesterone

prostaglandins ,

psychosocial development, disparity with physical development , ,

pubertal development

age of onset , 13–16, 22–3, 26–33

delayed puberty , 81–3, 117–18,130–1,132–4

duration of process ,

earlier puberty

key stages

measuring

precocious puberty 25–6, 80–1, , 131–2

research findings 11–12

puberty

blocking of ,

need for research on

need to talk about

purpose of 17–21

pubic hair , , , 61–2, 122–3

Quinlivan, Julie

reproductive system ,

resilience

right-wing populism 155–6, 158–9

risk-taking behaviour , 141–2

Rosewarne, Lauren 76–7

Rudaz, Celia Garcia ,

Safe Schools program , 156–9, ,

sanitary products ,

Sawyer, Susan , 104–6

secondary amenorrhoea ,

sex hormones, effect on brain

sexual assault , ,

sexual harassment

sexualisation of children in the media 100–1

sexualisation of young girls 41–2, 101–3, 105–6

sexualised behaviour 36–8,

sexuality education

age-appropriate content 40–1, 42–3, , 154–5, , , , ,

children's right to know 171–5

comprehensive sexuality education (CSE) ,

cultural reticence regarding

in England 162–3

lack of uniformity

in national curriculum 38–9,

need at earlier age 39–40

need for reform

outsourcing of 165–6

parental concerns over 38–9

Safe Schools program , 156–9

schools'/teachers' concerns about 150–1, 163–4

teacher training for , , , , 178–9

teaching of , , 164–5

timing of 15–16,

sexually transmitted infections (STIs)

shame , , , , , , , , ,

small penis syndrome

social media , 143–4, ,

special religious instruction (SRI)

spermarche

spontaneous erections , 128–9

Stern, Kate 88–9, , 92–3

stress , 176–7

suicide

Tanner scale ,

teachers

teaching of sexuality education 150–1, 163–5

training on sexuality education , , , , 178–9

technological revolution ,

teenager stereotype

Telfer, Michelle ,

testicular volume 119–20

testosterone , , , , , , 138–9

thelarche

transgender kids 156–8

Turnbull, Malcolm 158–9

Turner syndrome 82–3

vaginal discharge 63–4

voice 'breaking' ,

Von Willebrand disorder

Walsh, Jenny 165–6,

Ward, Roz

weight, and PCOS

wet dreams 128–9,

Williams, Florence 29–30

redpajama_set_name: RedPajamaBook