Table of Contents
Late-onset puberty can have anywhere from negligible to deep reaching physical, social, and psychological effects on the growth and development of male adolescents that follow them as they mature into adulthood. This paper will discuss some of the causes and effects of delayed puberty, as well as some known biological and psychological risks associated with it.
Findings
In most cultures, adolescence is considered the developmental time in life where a child begins their transformation into adulthood. This period is marked by obvious outward physical changes, hormonal changes, maturation of the prefrontal cortex, and countless complex internal processes that lead a child through the important work of developing their sense of self and where they belong.
Ninety-five percent of males experience puberty between the ages of 9 and 14. Late-onset puberty is defined as the lack of sexual maturation by age 14 in males, or puberty that doesn’t complete within 5 years of starting. The first clinical sign of puberty is the testicles enlarging over 4mL though overall pubertal development is measured using the Tanner scale, which also takes into account the more easily recognized outward signs of secondary sexual characteristics development (Taylor-Miller & Simm, 2017).
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While the majority of late-onset puberty is caused by what is called constitutional delay of growth and puberty (CDGP), most other cases are associated with problems with the hypothalamic-pituitary-gonadal axis (HPG), or a variety of other disease diagnoses (Wei & Crowne, 2015).
Constitutional delay of growth and puberty is also known as self-limited delayed puberty. It is a highly heritable autosomal dominant trait. Generally, one or both of the child’s parents will also have had delayed puberty (Howard & Dunkel, 2018) and in almost all circumstances of CDGP, puberty occurs without intervention and the physical body catches up with same-aged peers by the time the child reaches the age of 18 and exits adolescence (Zhu & Chan, 2017).
Late-onset puberty from other causes can be associated with growth hormone or gonadotropin deficiencies, genetic abnormalities, chronic diseases such as asthma or cancer, and gastrointestinal disorders such as celiac and irritable bowel syndrome. In HPG axis related delayed puberty, a component of those disorders involves luteinizing hormone failing to stimulate testosterone, and follicular stimulating hormone does not prompt the growth spurt & secondary sexual characteristics associated with puberty (Wei & Crowne, 2016). The cases often will not resolve without treatment of the underlying cause.
Nutrition may explain up to 25% of the variation in timing, both low birth weight and adolescent obesity may delay the onset of puberty (Soliman, De Sanctis & Elalaily, 2014). Malnutrition, anorexia, and overtraining in athletes can also keep puberty from occurring in a timely manner (Wei & Crowne, 2016). Understanding this as a factor and knowing potential longer-term effects of delayed puberty should be factored in when making decisions about the nourishment, diet and health of children.
The pubertal growth spurt is a noteworthy factor in the maturing male adolescent. Common causes of short stature are chronic disease, self-limited puberty, and familial short stature. Most boys with self-limited puberty will be shorter than peers of the same age. As mentioned before, these boys will generally finish puberty by age 18 and reach full height potential. In CDGP it seems to be the familial height that is the largest determining factor on final height, not the age when puberty is reached (Taylor-Miller & Simm, 2017).
The ability to reach a genetic target height is more complicated when late-onset puberty is not self -limiting. Each disease can have its own complications to factor into growth rate. In cystic fibrosis, height is correlated with pancreatic sufficiency, and that largely depends on newborn screening and early treatment. When a diagnosis is delayed until symptoms show in adolescence, it’s unlikely full height potential is ever met in adulthood. (Zhang, Lindstrom & Farrell, 2016).
A disease such as asthma not only delays growth if it is poorly controlled, but also delayed growth is a side effect of one of the main treatments, inhaled corticosteroids (Papi, Brightling, Pedersen, & Reddel, 2018). This makes it more clear that doing newborn screenings is vital, and that parents and clinicians are aware if children are developing appropriately so proper care can be provided where needed.
Studies suggest many boys with delayed puberty suffer from a negative self-image, and that this is largely due to being shorter in comparison to their peers, rather than from secondary sexual characteristics not appearing (Zhu & Chan, 2017).
There are a number of adult health outcomes that go along with delayed puberty. A UK Biobank study done in 2015 looked extensively at health and disease outcomes associated with early, normal, and late starts to puberty. They found asthma, obesity, eczema, dermatitis, IBS, sleep issues and overall poor health to be the most outlying common physical problems associated with late puberty. (Day, Elks, Murray, Ong, & Perry, 2015).
Studies have found that while being overweight is associated with early puberty, being obese is associated with late puberty in some races. A significant correlation exists in white and black adolescents, while weight did not seem to have an impact on Hispanic adolescents. (Lee, Wasserman, Kaciroti, Gebremariam, Steffes, Dowshen & Harris, 2016). A high body mass index during puberty is a predictor for adult obesity.
Not only is the mean BMI at puberty the strongest indicator for adulthood obesity, it was also found an increase in BMI during puberty was an independent variable that shows also predicts adult obesity (Li, Chen, Sun, Fernandez, Li, Kelly, He, Krousel-Wood & Whelton, 2015). While the general population in many cultures is aware of how obesity affects adults it can be overlooked that obesity in adolescence carriers longer-term risks.
A large study of healthy young Danish men showed participants who had CDGP to have reduced sperm count, production, and concentration, and referenced other studies showing HPG related delayed puberty also results in decreased semen quality. CDGP was correlated with frequent reported sexual problems & reductions in testosterone & luteinizing hormone, as well as an increase in follicle stimulating hormone. The researchers hypothesize that the timing of puberty may be an important biomarker of overall male reproductive health. (Kold, Folmann, Skakkebæk, Andersson, Olesen, Joensen,…Juul, 2016). Fertility issues are a stress point for many adults who are trying to conceive and understanding this aspect of late-onset puberty can help the process be less of a strain on couples.
While not an immediate danger as males leave adolescence, there is an increased risk of osteoporosis the later puberty occurs, and there will be a decrease in body mass index and bone density compared to post-pubertal males, (Zofkova & Nemcikova, 2018). While bone density compromise can be treated with sex-steroid therapy during the adolescent period, treatment is not effective once a boy leaves adolescence. Because peak bone mass is attained when skeletal growth ends in the mid 20’s it is important to try to maximize bone density during emerging adulthood if growth was delayed (Zhu & Chan, 2017).
An increased risk of Alzheimer’s disease exists, associated with the role that the timing of sex hormones and gonadotrophins play in cognition (Gurvich, Hoy, Thomas & Kulkarni, 2018). While this is another disease where symptoms will not surface until later in life, being aware of the risk gives the opportunity to help mitigate it by starting healthy habits to improve cognitive function in early adulthood.
Some positives exist when it comes to health and delayed puberty. A meta-analysis of studies suggest a 19% decrease of contracting testicular cancer in comparison to boys who go through puberty during the normal age ranges, and while studies conflict, a potential decreased chance of prostate cancer (Zhu & Chan, 2017). Some protection has also been found when it comes to cardiovascular and metabolic disease (Day, Elks, Murray, Ong, & Perry. 2015).
Psychosocial and psychological effects of delayed puberty largely fall under the category of affective disorders. The previously mentioned UK Biobank study also looked at psychological outcomes to pubertal timingre and found anxiety, panic attacks, bipolar disease, chronic fatigue and depression had significant positive correlations with late-onset puberty (Day, Elks, Murray, Ong, & Perry, 2015).
Some researchers have compiled meta-analysis of studies done on psychological issues related to puberty timing. Studies by Gaysina, Richards, Kuh & Hardy (2014) and Zhu & Chan (2017) concluded a number of negative outcomes for this group. It was concluded there were correlations between late-onset puberty, disruptive behavior disorder and drug and alcohol use/abuse in both adolescence and young adulthood, as well as this group having the highest rates of depression and anxiety among all male adolescents.
In another paper it was determined that when feelings of low peer acceptance or parental rejection were added into the mix or a child had previous behavioral problems from early childhood carried over into adolescence, these also provided an added significant positive correlation with depression levels present at the end of adolescence. (Benoit, Lacourse & Claes, 2013).
In cases where delayed puberty is a result of chronic disease, it is more difficult to tease out where social and psychological issues occur due to short stature and an immature appearance compared to their cohorts, versus symptoms caused by their illness.
Children with chronic diseases have a higher chance of experiencing delayed puberty (Wei & Crowne, 2016). Further complications of their illness can impact their psychological health as they may not only appear younger than peers but be treated as more physically and emotionally fragile than other children their age. Their lack of a sense of belonging can be compounded by missing more days of school and having less independence than others in their age group (Suris, Michaud, & Viner, 2004).
Treatment to artificially initiate puberty generally occurs in response to the stress children feel when dealing with the social ramifications of not developing at the same time as their peers. For chronic conditions and diseases, if relevant, hormone replacement is generally given by the age of 13 to help prompt pubertal development. With congenital delay, a wait and see attitude is often taken, though testosterone injections may be given if the stress caused by the delay is troubling the child or parents (Dye, Nelson, & Diaz-Thomas, 2018).
One last area of interest related to depression is where it overlaps with the individual’s psychological maturity. One study that looked into the low self-image, physiological immaturity, and negative feelings around sexuality associated with male late puberty and found a couple things of note. Boys with later puberty tended to have lower ego development, possibly linked to being treated as younger because of height and physical appearance. Also, the boys in this group who had higher ego development had higher rates of anxiety and depression than their less psychologically mature counterparts, with a hypothesis that they are more aware of, and concerned with, the physical difference between them and their peers who had already gone through puberty. (Lindfors, Elovainio, Wickman, Vuorinen, Sinkkonen, Dunkel, & Raappana, (2007).
Discussion
I started with little knowledge of late-onset puberty and was surprised to find such a wide-ranging variety of causes, each of which can have a different cumulative effect of mental and physical health during development. Narrowing the topic to congenital delay of growth and puberty, endocrine based causes or even “how does having asthma and late-onset puberty affect adolescence into emerging adulthood?” would have given a more focused paper, but I appreciate the chance to see how different systems tie together, how easily things fall out of balance in both the body and mind as they develop, and how one extra factor can change the a developmental period so greatly.
My expectations were to find much more written about the social and psychological effects, and I was surprised that the recent available-to-me research focuses on the health risks and outcomes stemming from late-onset puberty. When I think of late-onset puberty I tend to think of it as associated with social rejection, being left out of sports and some peer groups, and being picked on by children who have aggressive psychological problems. Because of the prevalence of bullying and school violence, especially in the US, I expected to have most of my research come from that direction.
The 2015 UK Biobank study discussed in the section above was an unexpected find, as I did not know anything about them. Compared to the smaller sample size of the majority of studies I found, it was a major step see the gathered information from 450,000 people (Caucasians) between age 40-70 and see a risk assessment of all the major diseases and be able to tie it into the physical and mental health aspects of how pubertal timing affected people as they developed. I did not discuss all the risks found, as I could not determine age of symptom onset or find research discussing risks during emerging adulthood for some of them.
While there are plentiful amounts of smaller studies on the health aspects of delayed puberty, there remain many gaps which can be filled in. The correlation between obesity, what percentage of delayed puberty is associated with obesity, and more about why it is such a strong predictor of adult obesity. The UK Biobank research also uncovers that much has to be explored about the associations of how bipolar disease and chronic fatigue syndrome in adult males is tied to pubertal timing.
There was a disproportionate amount of research found for late-onset puberty in females. Even in articles that started out with an evenly distributed sample of both males and females, few conclusions were drawn around boys, while there was often great elaboration how girls were affected. While it seems as if some of that may be due to the overall differences in how females communicate, that was not addressed in the papers or conclusions in most cases. Early-onset puberty in males is also covered far more widely than late-onset puberty is.
There are many areas I’d like to see more research in, and even the most recent papers I read tended to call out a lack of available studies, so the scientific community seems to be aware of the lack of attention to studying this group. Another problem I found, that with the dearth of research and so few studies, there are a number of places that information is still contradictory. Studies on late-onset puberty show correlation with both negligible and high risks of metabolic and cardiovascular disease. Prostate cancer is unrelated to puberty, or late-onset puberty may decrease your risks by 25%. Even the basic data was all over the place, congenital delay of growth and puberty was credited with anywhere from 53% to 90% of the delays, and I was unable to sort out what a reliable statistic was.
I discussed the 2007 paper by Linfors et al. at the end because I found the conclusions to be important topics, and could not find sources for further, or more current research on most of the aspects that roused my curiosity. Do late maturing boys actually tend towards lower ego development? If so, is that good or bad considering the more ego developed boys will feel the social effects and have more anxiety and depression simply due to the nature of being more psychologically mature and aware? Do the negative attitudes about sex resolve at some point during adulthood? Are there ways to mitigate and support adolescents that are developing differently in some more broad, useful way than one on one counseling?
Tying into ego development, one last area I ran across warrants much further research. I found a few studies looking into physical and hormonal changes during puberty and how they may be directly involved with the gray matter decreases & white matter increases that occur from adolescence into emerging adulthood. They look at the idea that puberty might slow, stop or possibly reverse some of the aging processes. Herting & Sowell (2016) discuss this topic as well as the lack of consistent results the limited amount of research has found to date.
Clarifying if pubertal timing affects the brain long term around this subject would be useful. If late puberty has a long term adverse effect on brain development, it is possible the “wait and see” being done in the cases of self-limited puberty could be detrimental, and if delayed puberty has a positive effect, families should be able to factor that into their choice to push puberty along with testosterone treatment, or consider if the hormonal treatment at age 13 for HPG issue should be started at 13 or delayed.
This subject connects to the association with Alzheimer’s disease that late-onset puberty shows correlation with. I avoided deeper discussion of the mechanics and science behind brain development, brain function and sex hormones, because it is out of my depth and scope to decipher and explain, but these are important areas to keep gaining understanding in.
Conclusion
The timing of puberty plays an important role in an adolescent’s physiological and physical health. Late-onset puberty has been shown to correlate with a number of systemic diseases, that affect health into emerging adulthood and beyond. While these aren’t all preventable, many of them can be tempered with knowledge and early action.
The internalization of anxiety and depression many puberty delayed adolescents develop and carry with them into adulthood is an area where the connections are understood, but most cultures do not have good systems and mental health care in place to mitigate the psychological effects.
Research has focused on the health and emotional effects of late-onset puberty, but more is being done to look at the bigger picture connection of the timing of interactions between brain development and the endocrine system and what that means for people in the bigger picture for long term health effects.
Hopefully the recent larger studies which shed light on some areas previously relatively unexplored will lead to a deeper understanding of the effects of intervening in the body’s natural development. Many areas of study still have great deficits where further exploration can help science with a much comprehensive understanding about how the timing of puberty affects health during the entire life span of a human.
References
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