From the Editor
Pediatric and Adolescent Gynecology: The Science is Coming of AgeThe Journal of Pediatric and Adolescent Gynecology (JPAG) is coming of age. I think we're beyond our childhood, continuing our journey through a journal's lifespan. In previous editorials, I've written about PAG and science, discussed the value of case reports, and addressed the maturation of the field of pediatric and adolescent gynecology.1,2 Each year, at the end of the calendar year, I review a report that is termed our “Accountability” report for the year. Throughout the year, David Newcombe, JPAG's wonderfully knowledgeable, consistent, and unfailingly dependable Managing Editor, sends me accountability reports on a weekly basis, allowing me to compare data with last year and previous years.
Reproductive Justice and Adolescents in a Post-Roe United StatesThe US Supreme Court's ruling in Dobbs v. Jackson reversed nearly 50 years of legal precedent following the Roe v. Wade decision in 1973. This decision was an assault on reproductive justice that disproportionately impacts adolescents and young adults. The decision allowed states to enact laws curtailing induced abortions; in some states trigger laws had been enacted prior to the overturn of Roe v. Wade leading to an almost immediate ban on abortions. Some of these laws have been enjoined from enforcement, but others have gone into effect.
The Association between Surgeon Dissatisfaction with Infant Genital Appearance and Surgical Decision-Making Surrounding ClitoroplastyThe study “Exploring factors associated with decisions about feminizing genitoplasty in differences of sex development” by Kremen et al aimed to address if Prader stage, clitoral size, parental uncertainty, anxiety, depression, or dissatisfaction with genital appearance correlated with surgical decision-making in children under age 2 with a difference of sex development (dsd). Most of the 58 children were diagnosed with 46 XX congenital adrenal hyperplasia (CAH), and all but 5 underwent surgery before age 2.
Early Puberty in Girls—What Do We Know in 2022?I remember 1997. Early puberty was THE topic of discussion among pediatric and adolescent gynecologists, adolescent medicine physicians, and pediatric endocrinologists. That year, Marcia Herman-Giddens published the landmark study entitled “Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings network.” The study included the findings that at age 8, 48.3% of African American girls and 14.7% of white girls had at least 1 sign of pubertal development, earlier than was suggested in standard pediatric textbooks.
Using the Menstrual Cycle as a Vital Sign: What We Still Want to Know about Adolescent Menstrual CyclesI remember the place and the conversation. Dr. Larry Nelson and I were attending an interdisciplinary women's health education retreat in Chantilly, Virginia, in 2000 and chatted over lunch.1 Dr. Nelson was with the U.S. Public Health Service, working at the National Institute for Child Health and Disease, division of intramural research, and is known for his important work on defining and addressing primary ovarian insufficiency (POI).2 Our lunch conversation was wide ranging, but the conversation struck a chord when we started talking about the menstrual cycle.
Pediatric and Adolescent Gynecology: Where's the Science?In 2010, I was asked by colleagues at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) to moderate a Pediatric and Adolescent Gynecology Research Think Tank Panel. I prepared a presentation on the science of pediatric and adolescent gynecology (PAG) in which I addressed the history of PAG, highlighting that PAG is a “young” and developing subspeciality, with an evolution of scholarship. At that meeting, I showed a chart (Fig. 1), which indicated that the type of article most commonly published in the Journal of Pediatric and Adolescent Gynecology (JPAG) was a case report.
Trauma-Informed Care in Pediatric and Adolescent GynecologyThe older I get, the more I reflect on how much has changed since I was a medical student. When I was in medical school, wife abuse (now characterized more broadly as interpersonal violence or domestic violence), child abuse or neglect, rape, and sexual assault were all occurring in our society and against individuals worldwide. Physicians had some awareness of these traumas—particularly if they had occurred in their own lives or in their own families, or if they had asked the right questions of individual patients.
Adolescents with Vulvar Ulcers: COVID-19 disease, COVID-19 Vaccines, and the Value of Case ReportsPrecis: Despite their limitations, case reports can be valuable additions to the medical literature. We should encourage frontline providers to submit case reports. Although a single case report cannot be used to draw inferences, a collection of high-quality case reports can inform hypotheses which can be tested in larger studies and can sometimes be synthesized into evidence to inform decision-making.
Call for Leadership: Climate Change and the Future Health of GirlsClimate change is the single biggest health threat facing humanity. In 2021, the climate crisis was visible to most of us. Examples of climate change included extreme heat and fires in the Western United States, floods in Central Europe, droughts in Africa, wildfires in Australia, and hurricanes throughout the globe. No one in the world is safe from the health impacts of climate change, but these effects are disproportionately felt by the most vulnerable and disadvantaged, not only those living in low- and middle-income countries.
Compassion Fatigue, Burnout, and a SabbaticalWhen I started my sabbatical in September 2020, I didn't realize that I was experiencing some signs of “burnout.” I would have said that I had always I loved my work, and would have denied that I was “burned out.” In truth, I was experiencing emotional exhaustion, and feeling that I wasn't accomplishing much with my work.
Contraceptive Counseling for Adolescents: Current Evidence and Road Map for the FutureThe past 3 decades have seen significant advancements in the area of adolescent contraceptive services and steady improvement in teen birth rates. Available contraceptive options have markedly increased. We have seen the expansion of short-acting hormonal contraceptive types, the entrance of long-acting reversable contraceptives, and the arrival of over-the-counter emergency contraception. Concurrent with this increase in contraceptive options and access, rates of teen births in the United States have steadily declined.
Pediatric and Adolescent Gynecology AdvocacyThis issue of the Journal of Pediatric and Adolescent Gynecology (JPAG) contains 2 very important statements from the Advocacy Committee of the North American Society for Pediatric and Adolescent Gynecology (NASPAG)—the NASPAG Position Statement on Gender Affirming Care for Minors, and the NASPAG Position Statement on COVID-19 vaccine and Gynecologic Concerns in Adolescent and Young Adults.1,2
Reprint of: Obstetric Trauma-Informed Care: Pregnant Adolescents’ VoicesAlthough rates of births to young women aged 15-19 years have declined significantly in the United States between 2007 and 2017, a total of 194,377 babies were born to young women in this age group in 2017.1 Numerous studies have established that social determinants of health such as race, low socioeconomic status, and inadequate education among pregnant adolescents are associated with adverse maternal and birth outcomes.2 Of special concern in recent years has been the effect of a history of trauma and adverse childhood experiences (ACEs) on pregnant and parenting adolescents.
Obstetric Trauma-Informed Care: Pregnant Adolescents’ VoicesAlthough rates of births to young women aged 15-19 years have declined significantly in the United States between 2007 and 2017, a total of 194,377 babies were born to young women in this age group in 2017.1 Numerous studies have established that social determinants of health such as race, low socioeconomic status, and inadequate education among pregnant adolescents are associated with adverse maternal and birth outcomes.2 Of special concern in recent years has been the effect of a history of trauma and adverse childhood experiences (ACEs) on pregnant and parenting adolescents.
A Pandemic Year: The Good, the Bad, and Social ConsciousnessSo much of the last year has been difficult for so many people. Activities that we used to take for granted—like seeing friends and colleagues every year at the Annual Clinical and Research Meeting (ACRM) of the North American Society for Pediatric and Adolescent Gynecology (NASPAG)—have been absent. Zoom was OK for the ACRM meeting content, but we missed the chance hallway meetings and chats, the dinner conversations, and the happy hour encounters that keep us connected to our colleagues across the United States and internationally, and that foster a group sense of purpose in improving the health of young and adolescent girls.
Pediatric and Adolescent Gynecology Is Care for the UnderservedWhen I was a resident in Obstetrics and Gynecology from 1977 to 1981, I had no idea what pediatric and adolescent gynecology (PAG) was. I'll save you the trouble of calculating how long ago that was; it's been 40 years since I completed my residency, and yes, that was a long time ago. As an ob/gyn resident, I learned about adolescent obstetrics, and I learned a lot about contraception for adolescents. Preventing adolescent pregnancies was clearly an important priority and educational objective. I also learned a lot about unplanned and unintended pregnancies, and learned the techniques of safe and legal first- and second-trimester abortions.
Moving Forward with HopeEven if you don't live in the United States, you are likely well aware of the recent US Presidential election. A record number voted; 66.5% of eligible voters cast ballots, the highest turnout rate since 1900.1 Of course in 1900, eligible voters included only men. African Americans and other people of color faced barriers at the polls, including poll taxes, literacy tests, and intimidation.2 It has only been since 1920 that women finally won the right to vote. As I am learning new realities of history beyond what I was taught in elementary school, I have learned that Native American women were not granted citizenship and the right to vote until 1924, with the Indian Citizenship Act, although some state laws still barred Native Americans from voting long after this date.
COVID, Science, Vaccines, and Public TrustAs I debated about what to focus on in my editorial for this issue of the Journal of Pediatric and Adolescent Gynecology (JPAG), I wondered if I should focus on something other than the COVID-19 pandemic. Surely readers are tired of hearing about the pandemic by now. I'm tired of it, and ready for us to be “back to normal.” BUT, as of yesterday, October 23, the number of people infected with the SARS2-COVID-19 virus hit an all-time 1-day high in the United States: more than 85,000 new cases were diagnosed.
Pediatric and Adolescent Gynecology (PAG) in the Time of a PandemicSometimes I struggle to decide what I will write about as a topic of editorials for the Journal of Pediatric and Adolescent Gynecology (JPAG). Other times, the news provides an easy choice of topics. Today, I am preoccupied with the topic at the forefront of discussions, news reports, and social media posts—the novel coronavirus COVID-19. As I write, on March 12, the situation in the United States is evolving—as it has been for the last few weeks, and will in the weeks to come in the United States and throughout the world.
Pediatric and Adolescent Gynecologic Problems Continue During the COVID-19 PandemicGreetings, dear readers, from shelter-in-place COVID-19 land, a very different place from where we all were (literally, and figuratively) when I wrote my last editorial on Pediatric and adolescent gynecology (PAG) in the time of a pandemic. Most of us are still reeling from the many changes that COVID-19 infections have necessitated.
Introducing a New Journal Club Feature for JPAGNASPAG, in conjunction with the Journal of Pediatric and Adolescent Gynecology (JPAG), is pleased to announce a new journal club feature. The journal club will be published quarterly online on the NASPAG website to highlight an article published in JPAG, with associated questions to help guide readers in critically appraising the emerging literature within the rapidly growing field of Pediatric and Adolescent Gynecology (PAG).
Pediatric and Adolescent Gynecology: What's It all About?Being the Editor-in-Chief of the Journal of Pediatric and Adolescent Gynecology (JPAG) continues to be an exciting job. Every other month, when I get the “pick list” of articles ready for me to select and order the articles that are ready for production in the next issue, I am reminded of the diversity of our field, which I've called a potpourri.1 For this issue, I am again struck by the breadth and depth of our field, but also by how the “mix” of topics changes with each issue.
Pediatric and Adolescent Gynecology—A Global PerspectiveYesterday, I returned home from Melbourne Australia and the World Congress of Paediatric and Adolescent Gynaecology (WCPAG). At least I think it was yesterday. I left Melbourne on Saturday December 7th at about 1:30 p.m., and arrived in San Francisco at about 4:30 p.m. on Saturday December 7th, having spent more than 24 hours on a plane or waiting in an airport. Strange, I think; I never did really understand the International Date Line. As Charles M. Schulz, cartoonist of Peanuts fame, is quoted as saying, “Don't worry about the world ending today; it's already tomorrow in Australia.”
Pronouns and PAGI confess that I really enjoy grammar, and have a passion for the English language and its words, phrases, clauses, sentences and parts of speech. I attribute this to my mother's similar enthusiasm, no doubt inculcated in me at a young age. When I started to learn to speak French in elementary school, I remember being puzzled that French nouns had grammatical gender. Why are some French nouns feminine (the table, la table) and others masculine (a book, un livre)? It doesn't make sense to me, and to this day I struggle in my attempts to learn the grammatical gender of nouns in other languages.
Vulnerable AdolescentsReading the titles of the articles in this issue of the Journal of Pediatric and Adolescent Gynecology (JPAG), the concept of adolescent vulnerability comes to mind. I am far from an expert on this topic that includes various models of health and risk behavior, but my colleagues in adolescent medicine and psychology have taught me several things: that there is a relationship between adolescent development and the development of poor health outcomes; that there are subpopulations of adolescents who might be particularly vulnerable to morbidities and mortality; and that behavioral risk factors contribute to those vulnerabilities.
Dilators for the VajayjayI have long been on a campaign to use anatomically correct names for body parts. My daughter will attest that she knew about her vagina from a young age; when we were teaching her the names of other body parts, I made sure to also talk about her vagina. I can say that she was as proud of her vagina as her younger brothers were about their penises. But those of us who see young girls for gynecologic concerns may need to ask moms about the colloquial words that are used in their family to describe the female genitals.
A Research Agenda for Adolescent Menstrual CyclesYes, I'm talking about menstrual cycles—again. I'm back on my soapbox, addressing the importance of the menstrual cycle. This time, it's prompted by an excellent review in this issue of the Journal of Pediatric and Adolescent Gynecology (JPAG) from Carlson and Shaw, “Development of ovulatory menstrual cycles in adolescent girls,” that deserves your attention.1 The authors summarize what we know about the anovulatory cycles that occur during the early gynecologic years—the first few years after menarche.
Pediatric and Adolescent Gynecology: The Potpourri of Our Clinical PracticesGreetings dear readers. Once again I collate the content for another issue of the Journal of Pediatric and Adolescent Gynecology (JPAG). Some months, as I review the list of articles that have successfully navigated the peer review process and have been accepted to JPAG I see major themes emerging that help me group the submissions. Typically there are several submissions relating to prepubertal gynecologic problems, several addressing contraception, a number that report on ovarian masses and surgeries, and typically some that pertain to medical issues such as heavy menstrual bleeding.
Conflicts of Interest and Trust in the Journal of Pediatric and Adolescent GynecologyI state at the outset: there is no scandal brewing at the Journal of Pediatric and Adolescent Gynecology (JPAG). Yet my editorial is prompted by an article in the Sunday New York Times (Times), titled, “‘Broken’ system lets doctors omit industry ties in journals.”1 This piece raises concerns about the influence of pharmaceutical, medical device, and biotech companies on medical research. In the article on the front page of the Times, a number of prominent physicians are called out for having failed to disclose financial relationships when their studies were published in medical journals as prominent as the New England Journal of Medicine.
Menstrual Cycles: Who Cares? We All ShouldThe first and most obvious answer to the question, “Who cares about menstrual cycles?” is that at least half of the world's population cares. In keeping with my penchant for true facts, as opposed to alternative ones, I fact-checked that percentage and found that according to data from the United Nations Population Division, reported by the World Bank, in 2017, women made up 49.558% of the world's population—basically close enough to half.1 Menstruation is a defining event for women, and its onset signals the beginning of the potential for reproduction.
The Peer Review Process and Celebrating Journal ReviewersThe Journal of Pediatric and Adolescent Gynecology (JPAG) and other scientific journals could not publish high-quality scientific reports without the behind-the-scenes work of individuals who contribute considerable time and effort to reviewing manuscripts. These peer reviewers receive little recognition beyond the Editors' heartfelt gratitude and the yearly publication of a list of the names of all of the individuals who provided reviews during the past year. Does anyone look at this list of names? I'm not sure, as JPAG hasn't tracked this, but I will confess that, I DO look at this list for other journals, to find the names of recognized leaders in the field as an indicator of the quality of the journal.
Puberty, Menarche, and the Menstrual Cycle: What Do We Know, and What Do We Teach?The process of pubertal development that ultimately leads to menarche is a critical process in the lives of all women. Understanding normal puberty and normal menstrual function is essential to understanding health and disease among girls and young women. It is crucial to the care that we, as pediatric and adolescent gynecologists and adolescent medicine specialists, provide. There is certainly a great deal about pediatric endocrinologic function that we currently understand, but our understanding is still evolving, and there are fascinating aspects of pubertal growth and trajectory that we do not fully understand.
Fired Up, Ready to Go-- Pediatric and Adolescent GynecologyIn my editorials for this journal, I get the opportunity to address the universe of Pediatric and Adolescent Gynecology (PAG) specialists—you, dear Readers. As I write my editorial today, I am returning from the Annual Clinical and Research Meeting (ACRM) of the North American Society for Pediatric and Adolescent Gynecology (NASPAG). I have attended this meeting almost every year since 1988, and invariably, when I return to my home institution, I am “fired up, ready to go”.
What is Pediatric and Adolescent Gynecology?When people ask me what I do, I gauge their time and interest. Are they asking out of general politeness, or do we have time for me to share more of what I do? I may answer that I am a physician, which can lead to their telling me a story about their latest encounter with the medical profession, or they may be curious and ask for clarification. If they express interest, I may respond that I am a gynecologist. I am sometimes parsimonious with even this information; I have learned that if I am speaking to a man, the conversation may quickly turn to another topic.