Before the pandemic, Vaishakhi Rustagi, a Delhi-based pediatric endocrinologist, found that cases of early puberty were pretty uncommon, but not unheard of: In a typical year, she would see about 20 such patients.
Then the pandemic hit, and the cases started to pile up. Since June 2020, Rustagi has seen more than 300 girls experiencing early puberty, she said.
Precocious or early puberty is defined as the development of pubertal changes among children earlier than what is considered normal, which stands at 8 for girls and 9 for boys. It's known to sometimes be caused by genetic syndromes, a family history of the disease, central nervous system problems, and tumors or growths on the ovaries, adrenal glands, pituitary gland or brain.
The phenomenon of increased cases during the pandemic hasn't been restricted to India - pediatricians across the world, from Italy to Turkey to the United States - have reported increases in precocious puberty cases. Parents have, too.
When Khyati first noticed blood stains on her daughter's dress last January, she assumed the child got hurt while playing; after all, at 8 1/2 , she didn't believe there was a chance her daughter could have started menstruating.
Khyati, a 38-year-old stay-at-home mom in Mumbai who is being identified by her first name only to protect her daughter's identity, told her daughter to change her clothes and check for cuts and scrapes. The child came back crying, afraid of the blood that was now soaking her dress, Khyati said. Over the next few days, the girl grew aloof, refrained from interacting with her family and wept incessantly, Khyati added. Increasingly anxious, Khyati approached a pediatric endocrinologist, and learned that her daughter, a second-grade student, was indeed having her first period.
Other things started to make more sense, Khyati said. She had noticed her daughter was developing breasts, but had ignored it, assuming the girl was too young to reach puberty. They hadn't even had the menstruation chat yet; Khyati was saving the talk for when she got a little older and was able to understand the process better. Khyati said her daughter grew disconsolate, and her family struggled to calm her tearful outbursts.
"She hasn't even told her friends about it," Khyati said. "Luckily, there were lockdowns, so no school. Otherwise, it would be very embarrassing for her."
While Khyati sees the lockdown as saving her daughter from the cruelties of the school playground, some doctors around the world are blaming the pandemic for causing accelerated puberty in the first place.
A study published in January of 2021 surveyed children across five Italian centers of pediatric endocrinology, and found that 328 girls were referred for suspected precocious puberty over seven months between March and September 2020, as opposed to 140 during the same period in 2019. The study concluded that there was an association between "the complex lifestyle changes related to the lockdown" and a higher incidence of precocious puberty in Italian girls, though no difference was observed in the incidence of early puberty among boys.
Pediatricians in the United States and India are also reporting cases of early sexual maturation, with girls as young as 5 developing breasts and those younger than 8 starting menstruation in some reported cases.
"I noticed that quite a few of my [girl patients] got their period after a lockdown," said Adiaha I.A. Spinks-Franklin, a pediatrician at Texas Children's Hospital.
In her cases, the girls were already in the early stages of puberty, with breast buds and pubic hair. But their periods were expected to be months, if not years, in the future, she said.
"Breast buds come at about 10 or 11 years, and then your period comes two years later. That's the normal process," Spinks-Franklin said. "From 9 to like 15, you're going through this process, but the stress of the pandemic sped up that physiological process. Meanwhile, socially and emotionally, they're still children."
In Delhi, Rustagi also believes the surge in early puberty cases is linked to the pandemic, which saw children holed up in their homes, with prolonged exposure to electronic devices, increased consumption of unhealthy food, increased stress and reduced physical activity - all factors known to increase the risk of early puberty.
"I think it's directly related to the amount of stress that the children have gone through," said Rustagi, adding lockdowns are not the only factor, with many children also coping with grief. "These children have lost family members."
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Early puberty is relatively uncommon, affecting about one of 5,000 to 10,000 children, with a female to male ratio of approximately 10:1. For doctors to see such a spike - hundreds of patients in Rustagi's case - is highly unusual, and a leading indicator of other mental and physical health problems.
In 90 percent of early puberty cases among girls, the cause is never ascertained. With the recent surge, said Rustagi, the cause cannot be identified for nearly all of her precocious puberty patients.
"We have to do all the investigations because we cannot call it idiopathic, which is causeless, without ruling out all other causes," said Rustagi. In one example, a 6-year-old girl who had started developing breasts was given an MRI scan and an abdominal ultrasound to check for tumors before being declared a case of idiopathic early puberty.
The average age of the onset of puberty has decreased over the last century, said Alok Sardesai, a pediatric and adolescent endocrinologist practicing in Mumbai. He added that while genetic factors play a major role, there is also consensus that environmental variables - such as weight, fetal nutrition, childhood dietary habits, physical activity and psychological factors - have an impact.
He pointed to two pandemic-related factors that could have led to the increased incidence of precocious puberty among girls: obesity resulting from decreased physical activity during the lockdowns and increased exposure to endocrine-disrupting chemicals (EDCs) at home. Sardesai added that he, too, has seen an increase in such cases since March 2020.
A September 2021 study carried out in Italy questioned whether there was enough evidence to link rising cases of early puberty with weight gain, but noted that the trend was clearly a real phenomenon in Italy and one that seemed to be related to "persistent changes in lifestyle" since the start of the pandemic, and not just limited to the lockdown period.
A recent Turkish study, which examined the data of all patients diagnosed with precocious puberty in a pediatric endocrinology clinic in Izmir, Turkey, also found a substantial increase in the number of idiopathic cases. The study compared data from the first year of the pandemic (April 2020 to March 2021) with the three preceding years. It found the number of girls diagnosed with idiopathic precocious puberty during the one-year study period during the pandemic was more than double that of any of the previous three years, with 58 cases of idiopathic CPP reported during the pandemic year compared to a total of 66 cases over the course of all three preceding years.
Sezer Acar, a pediatrician at Dr. Behçet Uz Children's Hospital in Izmir and one of the authors of the study, said they decided to investigate what was going on after seeing a sharp rise in cases.
"Previously, we used to treat one or two patients a month due to precocious puberty, but during the lockdown period I had to treat two or three patients a week," Acar said. "I asked my doctor friends in the city I lived in and in surrounding cities about this, and they also had noticed an increase in the frequency of precocious puberty."
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Among girls, precocious puberty leads to the development of breasts and pubic hair, in addition to acne, growth acceleration, menstruation, voice changes and other secondary sexual characteristics. It is also known to augment depression, eating disorders, substance abuse and anti-social behavior. A 2018 study that examined the psychological repercussions of early puberty on girls found that affected girls have higher anxiety levels, lower self-esteem and a more negative body image compared to girls who did not go through precocious puberty.
Rustagi, the Delhi-based pediatric endocrinologist, said the immense stigma around menstruation across the world can make life much harder for girls experiencing early puberty. She added that the mainstream treatment for the condition, a form of hormone therapy known as GnRH analogue therapy, is highly effective, but she suspects most patients never seek out treatment in India, where taboos around periods mean that the majority of women and girls suffer from a lack of awareness about menstrual hygiene.
"In many cases, parents refuse treatment for precocious puberty as they believe menstruation is a doing of God, and that meddling with menses would mean insulting the deities," she said.
Khyati faced a similar struggle when her daughter got her first period at 8 1/2 . Khyati lives with her parents-in-law, who insisted that the girl should not undergo the treatment, as menses were "God's gift" and interfering with them could lead to complications in the future.
"But my husband was adamant," Khyati said. "It was too early for our daughter. Now that treatment is available, we did not want to torture our child."
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Puja Changoiwala is an award-winning journalist and author based in Mumbai. She writes about the intersections of gender, crime, social justice, human rights and technology in India.
Erica Hensley contributed reporting from Georgia. She is a public health and data reporter with The Fuller Project based out of Mississippi and Georgia.
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This story was co-published with The Fuller Project.