Psychological
Implications
of Adolescent
Physical
Changes
in Girls
Ellen Rothchild, M.D.
Department of Psychiatry, Western Reserve University, Cleceland, Ohio
(Received October 7; accepted for publication November 17, 1966.)
ADDRESS: Department of Psychiatry, 2065 Adelbert Road, Cleveland, Ohio 44106.
PEDIATRICS, Vol. 39, No. 4, April 1967
“ANATOMY
IS DESTINY”
532
B
REFERRING to her developing breastsas “just baby fat,” a tomboyish
12-year-old indicated her hopeful anticipa-tion that they might disappear. The
para-phrase from Napoleon, that anatomy is des-tiny, was too painful for her to
acknowl-edge. Yet never more acutely than at
pu-berty, when physical change is so rapid,
does a girl’s anatomy influence her feelings about herself, her identity, her relationships to others and her role in life. Some psycho-logic meanings of anatomic sexual change,
their contribution to psychic growth, and the implications for pediatric management
are the subject of this paper.
Adolescence is not tile first period during
which a girl’s anatomy is important to her. As early as 2 or 3 years, children become aware of sexual differences, and girls
com-monly appear less pleased with the discov-ery than boys. Often one observes a little girl attempting to urinate standing up, stuff-ing a toy under a skirt to represent a penis, or preferring pants to dresses. Investigations
into comparative anatomy are rife among both sexes; children make endless compari-sons between themselves and other
chil-dren, between themselves and adults. These comparisons are not always openly apparent, and games such as “playing doc-tor” provide a vehicle for covert investiga-tion. For the young female who feels cheated
it is hard to be told that never will she have a penis but if she waits long enough she will
someday have what her mother has-big
breasts and babies. The early years, during which little change is apparent in bodily sexual characteristics, serve the girl as a
pe-riod during which she can begin to accept her anatomy. By school-age many girls have settled for being dainty and feminine
though sone remain dissatisfied tombovs.
Not until puberty do the obvious feminine
sexual changes place a final, irrevocable
stamp on a girl’s identity as a female.
The vicissitudes of previous development and experience contribute to individual variations in the pubertal girl’s acceptance of her anatomy. Feelings about her new,
changing body vary from one adolescent to
the next, as well as being mixed-both
posi-tive and negative-within the same individ-ual. The attitudes of others affect her
satis-faction with herself. One can anticipate that the girl whose mother takes pride in her femininity and is at ease with her role
of childbearer, childraiser, and domestic
chief-the girl whose parents have enjoyed her for being a girl-will accept with some pleasure her new adolescent changes. Less
delighted will be her counterpart, the girl
whose family longed for a boy and raised her figuratively, if not literally, with a base-ball mitt in her hand.
Few girls can report directly and
ac-curately how they feel about their pubertal
changes. Regarding menstruation, Anne Frank confided in her diary:
I think what is happening to me is so wonderful, and not only what can be seen on my body, but
all that is taking place inside. I never discuss myself or any of these things with anybody; that
is why I have to talk to myself about them. Each time I have a period-and that has only
been three times-I have a feeling that in spite of all the pain, unpleasantness and nastiness, I have a sweet secret, and that is why, although it
is nothing hut a nuisance to me in a way, I always
long for the time that I shall feel that secret within me again.’
Ordinarily, on asking a girl of 14 or 15 for retrospective information regarding her
ARTICLES
outline of how she knew all about what to expect beforehand and how unremarkable
everything was. To learn more one must be present at the time or else read between the
lines. And, in contrast to the incisive
quali-ty of menarche, the more gradual develop-ment of secondary sex characters evokes
reactions which are likely to be
remem-bered and reported with even less
accura-cy.
REACTIONS TO THE DEVELOPMENT OF SECONDARY SEX CHARACTERS
If one observes junior high school girls as
a group, one is struck with the importance
physical growth assumes; how well a girl is
“stacked” becomes a factor in her status
among her peers. By seventh or eighth
grade, some girls are vell advanced in
physical development while others are no-where near so; discrepancies vitally affect
selfconcepts.2 Researches into bodily
com-parisons, frequent in preschool years, are
revived again in the junior high school girl who may be well aware of and deeply inter-ested in how she compares with her peers.
Many girls can list for one both qualitatively
and quantitatively the degrees to which each individual in the class has developed, right
down to what bra size each wears. Locker room comparisons may be sufficiently em-barrassing or exciting so that a number of
girls try to avoid gym altogether, and the
request to tile pediatrician for a medical
ex-cuse on some flimsy grounds is common.
As individuals, apart from tile group,
girls can feel self-conscious anywhere.
A 15-year-old girl described feeling certain that,
as she walked down the street, every male eye was appraising and mentally undressing her. While one part of her was proud, another part wanted to
slouch over and hide. She reported, “I don’t really know how I should be feeling.”
Other individual concerns relate to leav-ing childhood and becoming an adult,
sex-ual woman:
Such was the dilemma of the girl who passed off her breast development as “baby fat.” A similar
anxiety sometimes underlies the shaving of pubic
hair.
Some girls appear to welcome breast develop-ment with exaggerated delight as if it were some-thing to flaunt and show off. Among these there are a number for whom breast development does
not represent a feminine attribute as much as it does an acquisition now finally comparable to what boys have which the girl feels she has so far lacked.
The genital sexual implications of developing a
“shape” were clearly expressed by a 12-year-old who made up rhymes about “shape” and “rape.”
She explained that the dangers of having a “shape” could be avoi(led by behaving like a “rack.”
Ordinarily the conscious feelings about
external bodily changes are most often mixed ones of pride, self-consciousness,
misgivings and pleasure. Many of these
feelings are reflected in the tremendous
in-vestment girls make in their physical
ap-pearance; hours can be spent in narcissistic preoccupation with dieting, skin care, hair
styles, and fashion. Displacements away
from the body may be represented by more
sublimated “styles”-a girl’s adoption of a particular personal manner of speech or
gesture which she calls her own, her own
individual tastes, interests, beliefs and
choice of friends.
REACTIONS TO MENSTRUATION
Reactions to menstruation are at least
as varied as those to external physical
changes. Age-old cultural attitudes of awe
and dread of the menstruating female no doubt contribute, in some measure, to the individual girl’s reactions. In many
primi-tive societies taboos are placed against the menstruating woman touching or
associ-ating with others for fear she might bring about disease, injury, emasculation, or even
death. Pliny’s Natural History, written in the first century A.D., recorded that
men-struating women turn wine to vinegar, kill bees and seedlings with their touch, turn milk sour, and cripple horses. And, though there is no medical basis, similar supersti-tions and taboos persist in present day
be-liefs that during her menses a woman should not shower, wash her hair, have in-tercourse, ride horseback or eat certain foods.
un-realistic attitudes were blamed on lack of enlightenment. Havelock Ellis cited a
now-classic report from the French press in which a girl of 15 threw herself into the
Seine River: “She was rescued and on being
brought before the police commissioner, said that she had been attacked by an
‘un-known disease’ which had driven her to
despair. Discreet inquiry revealed that the
mysterious malady was one common to all women and the girl was restored to her
insufficiently punished parents.”
In this day of fifth grade hygiene movies,
when, if her mother, her sisters, or her
friends have not enlightened her, the school
will, girls know much more about the whole reproductive process and their role in it than they did a generation ago. Yet, though girls are prepared in the schools for the biologic changes, they are seldom prepared for the changes in feeling. Side by side with
a conscious awareness of medical facts, even the most enlightened adolescent may entertain her own private sentiments.
Though not necessarily conscious, certain feelings and ideas commonly exist which
are at variance with all our attempts at ra-tional explanation and preparation.
One set of ideas is that this monthly
dis-charge of waste material signifies that the girl has nothing but a dirty, disgusting hole; since there is no sphincter, the girl cannot
even control what emerges.
A prepubertal girl believed that menstruating
would be akin to wetting the bed. She was quite sure that boys never wet for they can so much
better control where they urinate.
A post-menarcheal girl connected the darker
color of menstrual blood with dirt, sin and disease. Some girls handle the feelings of shame and
disgust by refusing to wear sanitary napkins, hid-ing their soiled underclothes and telling no one
of their periods.
Another idea is that to bleed must mean
that the girl has been injured, damaged or not made right.
Immediately after attending her school hygiene movies on menstruation, a 12-year-old girlregaled me with “sick jokes” (i.e., “No, of course you can’t go swimming. You know your hooks will get rusty”).
She told a ghost story about a girl whose feet were “bloody stumps,” and she complained of having
broken several things that day-her glasses, her
transistor radio. Further discussion confirmed that
the movie had roused ideas of damage and
mu-tilation.
For all their previous enlightenment, on their first bleeding some girls must return in horrified
disbelief to check the toilet seat for the nail or
piece of glass which must have cut them.
When the idea exists that genital
bleed-ing represents an injury, a girl may feel somehow responsible by virtue of
some-thing she has done, such as masturbate.
In an effort to deny any connection, when asked
what she understood about menses, a 13-year-old girl replied suavely, “Oh yes, I know all about that.
Girls menstruate and boys masturbate.”
Such ideation may impel a girl at men-arche to relinquish old habits which she
views as dirty and uncontrollable, such as masturbation, thumb-sucking, or enuresis.
An 11-year-old girl was unable to fall asleep at night without simultaneously sucking her thumb and stroking a pair of her brother’s underpants. Though ashamed of the habit she was unable to give it up. Returning from a summer vacation, she reported proudly that she no longer sucked her thumb. When I asked how she had accomplished this feat, she described accompanying her father
on a trip to New York City where she had gotten
dressed up, dined at Trader Vie’s, and attended a Broadway play. She explained that she had felt so grownup and, reflecting that it was too babyish to continue sucking her thumb, she had forthwith given it up. To me this seemed an insufficient
stimulus to renounce such a tenacious habit.
Sub-sequently her mother told me that on the night the girl went to the theater she had had her first period.
This is not to suggest, however, that
ado-lescence is the long-awaited remedy for habit disorders.
The commoner conscious attitudes
usual-ly parallel those described by Anne Frank. Girls seem generally to regard their periods as something of a nuisance but well worth exploiting as an excuse from gym, as a pres-tige item among their peers-having “joined
the club”-and as a source of pride and pleasure in becoming a woman and now being able to bear children. Since little has
actually changed in the girl’s status, there is
ARTICLES
IMPLICATIONS FOR PSYCHIC GROWTH
Differences in the psychological
sig-nificance of the first dramatic pubertal
physical experiences-the boy’s first
ejacula-tions and the girl’s menarche-lend truth to the statement of the girl who differentiated
the sexes by masturbation and menstrua-tion. The boy’s first emissions, usually
or-gastic and frequently leading to masturba-tion, contrast strikingly with the menstriiat-ing girl’s avoidance of touching her
bleed-ing genitals. Thus, boys are likely to experi-ence more conscious guilt than girls be-cause of the accompanying erotic activity. Though proud of the other visible manifes-tations of their new-found virility, boys
usually take exaggerated precautions to hide the evidences of wet dreams, perhaps
only secretly discussing or demonstrating
ejaculations among their fellows. Girls, freed from such conscious guilt, are more
openly proud of their menarche and may
advertise it not only to friends but even to adults. On a less conscious level, the pain associated with menstruation further as-suages the girl’s guilty feelings; if she has
engaged in the forbidden, then the painful
aspect of her menses can seem a penance
for wrong-doing and helps to wipe the slate clean .
If her periods are fairly regular a girl has some psychologic advantage over a boy in that this bodily phenomenon is stable and predictable in contrast to the unpredictabil-ity and uncontrollability of the pubertal boy’s spontaneous erections and nocturnal emissions. The pain which accompanies menstruation can be localized to a specific
part of the body which the girl could not previously feel, aiding the girl’s orientation to her physical boundaries at a time when
they seem to change so rapidly. When a girl is fortunate enough to settle rapidly into
regular cycles, then this predictable event with its localizeable sensation can serve the girl as an organizer, a nidus around which she can build some of her developing sense of physical and psychological self. Yet,
re-gardless of its regularity, the recurring Ian-gor, discomfort, and bleeding, all
ultimate-‘y’ to be associated with child-bearing,
fos-ters the girl’s shift in orientation away from active tomboyishness to a more passive,
yielding femininity.6
At least as far-ranging in effect, for both
sexes, is the influence of sexual maturation
on shifting family relationships. While the
girl is developing into a shapely young woman, her mother may in the meantime
have become a little greyer, perhaps a little
dumpier. The girl is now in a far better po-sition to compete with her mother for a man than she was, say, at 3 when she was told she must wait for a seeming eternity before gaining her mother’s mature femi-nine endowments. While agreeable in some
ways, the more equal sexual footing of
mother and daughter also enhances conflict
for the girl. Pleased on the one hand, a girl can also feel guilty that she now has the po-tential for outdoing her mother in the
pop-ularity contest. Such feelings of conflict
may underlie some of the familiar teenage behavior of dressing like a slob or being as
unlike the mother as possible in other ways, eschewing parental mores or picking fights
with a parent who “doesn’t understand.” If she dresses like a beatnik, then how could
she possible be attractive? And, if she can invite punishment, then her guilt may be assuaged. The well-known obnoxiousness of
this period, the slammed bedroom doors and hostile silences are accompanied by a general move out of the home in favor of more engrossing relationships with peers.
While this is trying to parents, it is vital
that the adolescent make this move to in-dependence. If she is not to remain tied forever to home and parents, if she is to
grow and develop a separate, distinct iden-tity, the adolescent must remove herself to the world of her peers where she will ulti-mately live, work, and love.
THE ROLE OF THE PEDIATRICIAN
W7hen the adolescent girl’s physical de-velopment and her concomitant
be-comes more one of an interested and sym-pathetic observer who stands by ready to help out as needed. When significant devia-tion from the norm exists, the demand is
greater for the pediatrician to examine, fol-low, treat if necessary, and offer explana-tion, discussion and re-explanation. Adoies-cents vary in their ability to accept medical
care. Many can manage their own appoint-ments, give better histories than their
par-ents, and carry out instructions reliably; others retire in favor of parental authority.
At times the same individual may appear mature and reasonable one moment, flighty and irresponsible the next. There is a dan-ger of our meeting the girl with the
ex-pectations accorded either a child or a grown woman when the teenage girl is si-multaneously both and neither. For the
un-stable internal physiologic equilibrium of adolescence is paralleled by a remarkable, if transitory, emotional instability, which is
manifested in wide swings of mood and mercurial fluctuations of interests,
atti-tudes, and relationships. The task of be-coming used to a new, changing body and personality is accompallied by a temporary
lessening of the adolescent’s sureness of herself, of her ability to anticipate and con-trol her reactions. If the teenage girl’s
per-sonality is relatively unpredictable, then the physician cannot be too rigid in his expec-tations and approach. Even to talk with the girl can be difficult at times.
In talking with teenage patients, some
pediatricians hold a routine “adolescent talk,” something of a run-down on
repro-ductive physiology. Most girls have already
heard this before, either at home or in school, and the chief positive function such discussions serve is to indicate the pediatri-cian’s willingness to act as a counselor and potential healer should the girl run into
trouble. Such talks can do more harm than good if, in his therapeutic zeal, the
physi-cian presses too deeply for information the patient is not yet willing or ready to share. In contrast to talking with the grade
school-er, it is easy to make the adolescent say too
much, to force confessions from her and
have her lose control of her emotions.
A 15-year-old was disturbed by her boyfriend’s petting practices hut only hinted her concern to the doctor in highly indirect fashion. After only a
few minutes the well meaning physician guessed
aloud that the girl was troubled about possible harm from kissing genitals. When the girl nodded
in silent embarrassment, he delivered a lecture on proper sexual relationships. The girl broke off with
the boyfriend and the physician, feeling unable to
control her relation iyith either.
When the adolescent patient’s control of what she reveals is so shaky, it may be wiser for the physician not to be too active
initially, perhaps even to appear a little stu-pid. Rather than seeming an omniscient mind-reader who can discern the
unmen-tionable, tile prudent physician may turn control of what is said over to his patient. Then, when she can trust her own control and that of the doctor, the adolescent may
feel more willing and able to scrutinize her
problems with ilim on this occasion or a
fu-ture one.
Respect for privacy of the body parallels
that for the privacy of the mind. Tile ado-lescent who appears nonchalant about
sexu-ality can lead the physician to be too casual in his approach when examining her.
Be-hind the girl’s apparent unconcern often lie doubts: is she made right or will the doctor
discover some devastating abnormality? Ample quantities of sheet in which to drape herself are as important for the barely de-veloped girl as for her more highly en-dowed, sometimes overly exhibitionistic sis-ter. It seems necessary to mention this only because medical modesty may be a vanish-ing cultural practice.
A college sophomore, spending a summer abroad, developed prolonged menorrhagia and was ad-mitted to a French hospital for a D and C. To her astonishment she found herself being wheeled on a stretcher through the hospital corridors quite naked.
Perhaps the French have achieved a
higher level of sophistication; young
Ameri-can womanhood has not yet reached this pinnacle.
ex-ARTICLES 537
amination as to shake hands with his pa-tient. Though this may hold for the adult,
routine internal examinations are unneces-sary for the adolescent. While it has been
argued that, given sufficient prepubertal
experience with pelvic investigation, the
adolescent can and should undergo routine
vaginal n’5 many physicians
who deal with adolescent girls are less
en-thusiastic to rush in with the full diagnostic
armamelltarium and prefer to weigh each
case individualiy.9u1 Probably the
chrono-logic sense of the term “adolescent” should
be broadly interpreted; in general, the
younger the adolescent, the more acutely
sensitive she is to any genital investigation.
Her modesty is affronted by it, and in the
semise that the conditions of the examination
re(Iuire her to submit passively to a genital
penetration, she may-consciously or
not-imagine the experience as a seduction or
even as a sexual attack.
A 15-year-old, confiding to a friend her first
experience with vaginal examination, reported solemnly, “I lost ni virginity today.” Beneath the apparent jest lay the girl’s equation of the exam-ination with intercourse.
Some girls fear they viil lose control on the examining table, for instance by urinat-ing or betraying pleasure in the genital
stimulation. If the girl is tense, the resulting pam of tile examination can support her no-tion of tile painfulness of intercourse and
childbirth.’2 Every girl I have known vell enough has told me of her certain dread
that the gynecologist would somehow
dis-cover her past or present masturbation. Under certain conditions tile examination can be come interwoven with, and main-tain, conflicts over sexuality.
A 15-year-old girl repeatedly sought examin-ation for complaints of lower abdominal pain. For a vaginitis, at age 9, she had undergone pelvic examination and was treated with douches and
suppositories. As a teenager, despite several CI and pelvic work-ups, she remained unrelieved by
as-surances that no organic basis existed for her
com-plaints. After several visits to a psychiatrist she gathered courage to confess her struggles to con-trol her masturbation, her fear that masturbation had caused her vaginitis in the past and must
surely be harming her in the present. The past and present vaginal examinations and treatment she
experienced as both a punishment and a pleasure
which she felt driven to repeat.
\Vhereas many girls probably take the
medically warranted vaginal examination in
their stride, for some it serves as an experi-ence around which to focus and perpetuate
existing conflicts. Although pelvic
examina-tions may be quite feasible mechanically, it
is the psychological significance which
checks the routine examining hand.
One examination to be most cautiously approached is that requested by the
overly-interested parent, anxious to check on the
virginal condition of the girl’s genitals.
An-atomically tile establishment of virginity is often problematic,13 and in any case the cx-amination is scarcely a guarantee against
future intercourse. The physician who ac-cedes to such a parental request becomes
partner to the parent’s excitement, thereby
reinforcing the effects of the parental
con-cern on the girl. A somewhat similar situa-tion can arise in a hospital emergency room
when an anxious family rushes in the child who has allegedly been raped. A hasty vag-inal investigation, undertaken under highly
emotionally charged circumstances, can feel to the girl like a repetition of the real
or imagined experience, thus cementing in her mind the psychological effects. Though harder and more time-consuming than a
pelvic examination in both situations, a ver-bal examination with both parents and
child, individually, may be more diagnostic. A single talk with the too intimately inter-ested parent seldom diminishes the
excite-ment for long; when such parents
subse-quently feel the urge to cross-examine the
girl after a date, for instance, I have sug-gested they call me instead. When rape is
in question, preventive medicine can some-times be practiced by postponement or omission of the vaginal examination, though each case must be individually judged.
Aside from thorough history taking, other
determine endocrine functioning. Rectal examination has been advocated for the
younger patient,9 though whether there is
any psychological advantage to its
substitu-tion for a pelvic examination has been
questioned.12 The male physician can turn over to his office nurse matters of demon-stration, such as the girl’s locating her
vag-ma in the use of suppositories or tampons.
Of course, if there is a valid medical rca-son for vaginal examination, there is no
question about proceeding with one. The
potential emotional significance of the cx-amination, however, implies the need for
adequate psychologic preparation to help mitigate the effects. The girl should be told that she may feel some discomfort but no actual pain, or if there will be pain, that she will be told in advance. The use of warmed
instruments, sufficient lubricants and some
neutral vocal anesthesia may obviate the need for general anesthesia. Both physician and patient are protected by the presence of the office nurse-chaperone. An explana-tion of the findings and reassurance as to
normality, when appropriate, should follow the examination.
When psychologic considerations dictate a flexible, sometimes relatively inactive ap-proach to the adolescent, the question might be asked, who needs the treatment most? Although physical and psychologic adolescence places many stresses on the
course of growth, most girls traverse their adolescence quite successfully and it is the parents who emerge bruised from the
expe-rience. Judicious hand-holding, explanation and anticipation that this too will pass, offered to parents, can frequently carry a girl farther than some of our frantic efforts to deal directly with phenomena which ap-pear initially so disturbing yet are often so ephemeral in the course of normal
adoles-cence.
SUMMARY
Though of fundamental biologic impor-tance, the anatomic sexual changes of ado-lescence are also decisive for psychic growth. These changes are welcomed with
a variety of emotional reactions and serve, psychologically, to consolidate a girl’s femi-nine identity and support her eventual
growth toward individuality and indepen-dence. The physician’s approach in man-aging this aspect of adolescent growth can facilitate or hinder progressive emotional development. Bearing in mind the
psycho-logical implications of adolescent sexual
changes, the physician can help pave the
way for the teenage girl’s continuing
physi-cal and psychological maturation.
REFERENCES
1. Frank, A. : The Diary of a Young Girl. New
York: Doubleday and Co., p 143, 1952.
2. Schonfeld, W. A. : Body-image in adolescents:
a psychiatric concept for the pediatrician.
PEDIATRICS, 31:845, 1963.
3. Ellis, H. : Studies in the Psychology of Sex,
Vol. 2. New York: Random House, Part 3,
p. 66, 1942.
4. Jacobson, E. : The Self and the Object World. New York: International Universities Press, pp. 162-164, 1964.
5. Kestenberg, J.: Menarche. In Lorand, S., and
Schneer, H. I., ed.: Adolescents: Psychoan-alytic Approach to Problems and Therapy. New York: Hoeber, p. 19, 1961.
6. Deutsch, H.: Psychology of Women, Vol. 1.
New York: Crune and Stratton, p. 172,
1944.
7. Allen, E. D.: Examination of the genital organs in the pre-pubescent and in the adolescent girl. Pediat. Clm. N. Amer., 5: 19, 1958.
8. Parsons, L., and Sommers, S. C.: Gynecology.
Philadelphia: W. B. Saunders, p. 2:3, 1962.
9. Gallagher, J. R.: Medical Care of the Adoles-cent, ed. 2. New York: Appleton-Century-Crofts, p. 271, 1966.
10. Heald, F. P., and Sturgis, S. H.: Adolescent
gynecology-a five ear study. PEDIATRICS,
25:669, 1960.
11. Sturgis, S. H., et a!.: The Gvnecologic Patient. New York: Grune and Stratton, pp. 67-68, 1962.
12. Josselvn, I.NI.: Psychological effect of the Men-arche. In Kroger, W. S., ed.: Psychosomatic Obstetrics, Gynecology and Endocrinology.
Springfield, Illinois: Charles C Thomas, p.
84, 1962.
13. Schauffler, C. C.: Pediatric Gynecology, ed. 4.
