Pubertal development

• On the basis of large observational studies and consensus, the normal time for girls to begin puberty is between 8 and 13 years and for boys is between 9 and 14 years. • On the basis of multiple recent observational studies, there is a secular trend toward earlier puberty in boys and girls. (2)(4)(11) • Although the triggers for puberty are still not fully understood, recent cohort studies have shown that obesity advances the onset of puberty in girls and possibly in boys. (6)(17) • On the basis of observational data, menarche is advancing more slowly than thelarche and occurs earlier in girls with elevated body mass index. (4)(6) • On the basis of observational studies, chronic diseases and malnutrition can delay the onset of puberty. (15)(19) • Although pubertal onset is occurring earlier, cohort studies have confirmed that the relationship between growth velocity and Sexual Maturity Rating (SMR) has remained consistent. (12) • On the basis of strong evidence, girls have their pubertal growth spurt earlier than boys, usually between SMR 2 and 3, compared to SMR 3 to 4 for boys. • Gender dysphoria should be evaluated and managed by a multidisciplinary team with experience in adolescent developmental psychopathology. (20).