by Chris Hamre, May 2008

In this age, when image seems to matter too much, many people will try different methods to alter their appearance. Women will try breast enlargements, balding men will resort to wearing hairpieces, and the overweight will have procedures such as liposuction or gastric bypass. Now even the short-statured can add inches to their height by going through painful limb-lengthening procedures or by taking growth hormone as children. I will be talking about the latter procedure in this paper and say that, for the most part, with the exception of using human growth hormone (HGH) to treat a medical condition, the use of it in children who are otherwise healthy but short (idiopathic short stature) is cosmetic and does nothing but perpetuate a prejudice against shorter people; especially men.

So, the issue is, should these children be actually receiving growth hormone, which would come at a significant cost, a risk of side effects, and only a modest gain in height of two or three inches of which there is no guarantee? Is their shortness a disease that needs a cure or are the parents doing the kids a disservice in the long term? After treatment, these children will still be short in stature and feel the sting of a society that demonstrates a proclivity towards the taller.

Proponents of its use will suggest that these children need it for the sake of their future and better opportunities. One argument is that these children should be able to receive this treatment just as children who are short due to a medical condition. In 2003, the Food and Drug Administration (FDA) approved the use of human growth hormone for children with idiopathic (no known medical reason) short stature, whose projected height will be no more than 5'3" for males and 4'11" for females. However, most of the cost will be covered by the parents; many will pay upwards of $20,000/year. Since it is labeled as cosmetic, most insurance companies will not cover it. Yet, parents argue that their children will still suffer bullying and teasing in school, will have to struggle later in life (such as dating and in the workplace) and that it shouldn't matter if they have a medical condition or not.

These parents do have a legitimate complaint. In 2003, four research studies were conducted by Professor Timothy Judge of the University of Florida, as well as Professor Daniel Cable of the University of North Carolina. These studies revealed that there was a wage disparity between the tall and short and that height was more of a determining factor for wages than was gender. They found that, on average, for every inch of height, a person could be expected to make $789/yr more than someone an inch shorter. So, an individual with a height of 6'0" would make almost $5,600 more a year than a person of 5'5". Professor Judge arrived at the conclusion that "Height matters for career success."

Dating is also a chore for the shorter man. In an episode of 20/20 in 1996, shorter men were put in a lineup and given many appealing traits and as much as fifteen women participated. When these women were asked if they would date these men, the verdict wasn't good for short men; most of them said no. One woman stated that his personality would have to be off the charts to consider him. A couple of the women said that they would only consider dating them if their only other choices were murderers or child molesters. So, knowing this, who then can blame parents for wanting to give their child the best chance for a better life?

Opponents of this use in these children will say that it is mostly for cosmetic purposes and it isn't necessary. These children do not have a medical condition and using it can perhaps put their future health at risk. They can suffer from headaches, abnormal bone growth in the face and hands, as well as put themselves at risk of diabetes and cancer. If the child is not suffering from any psychological effects from their short stature and is just the average child, ethicists and opponents do not recommend that the child receive treatment; parents run the risk of stigmatizing the child when there isn't anything wrong with them. For the children who suffer from some trauma about their short stature, they should be told that nothing is wrong with them.

Also giving a child growth hormone may just rob them of an extra inch or two, since HGH injections not only speed up growth but also the pubertal stage. This can cause the growth plates to close earlier than normal and rob the child of one or two years of adding on some inches.

So, taking these issues on both sides into account, are parents ultimately wasting obscene amounts of money on this treatment and are they better off reinforcing a positive self-image on their children or are two or three inches really that important? Dr. Ray Hintz, who is a pediatrician and a paid consultant to the pharmaceutical company, Genentech, said in a 1999 article in the New England Journal of Medicine, "If there were no long term benefit of growth hormone treatment for these children, there'd be no reason to treat them and therefore no ethical dilemma." However, Michael Sandel, who was invited to serve on the President's Council on Bioethics in 2001 and wrote a book entitled, "The Case Against Perfection", said this: "It is tempting to think that bioengineering our children and ourselves for success in a competitive society is an exercise of our freedom. But changing our nature to fit the world, rather than the other way around, is actually the deepest form of disempowerment." (Sandel, pp. 96-97)

So, how much money is being spent on human growth hormone for these children? Well, the major pharmaceutical companies such as Eli Lilly, Pfizer and Genentech scored big after the 2003 ruling by the FDA. These companies manufacture synthetic growth hormone and according to Stephen Hall, author of "Size Matters: How Height Affects the Health and Happiness of Boys and the Men they Become", Pfizer sold $736 million worth of their brand Genotropin in 2004; Eli Lilly sold $430 million worth of Humatrope and Genentech (the original manufacturers of the synthetic form) sold $354 million. Other companies that manufacture this substance are Novo Nordisk and Serono. According to Joyce Lee, a pediatric endocrinologist at the University of Michigan, treating 10 percent of the estimated 400,000 children who have idiopathic short stature (ISS) in the United States would cost $4 billion.

Ms. Lee also pointed out in her studies that growth hormone use in boys was twice as high as for girls, considering the fact that there is more pressure on boys to be taller than there is for girls. Prior to growth hormone treatment, taller girls were given estrogen shots which would advance their pubertal stage and thus their bones would fuse together quicker and stop their growth process, so that they wouldn't feel awkward being taller than the males.

How about side effects to this treatment? For synthetic growth hormone use, there have not been any severe side effects reported; however, there is potential for arthritis, possible cancer, headaches and abnormal bone growth. This has not always been the case with growth hormone treatment.

Prior to 1985 and the development of synthetic or recombinant growth hormone, this substance was obtained from cadavers; a practice which began in the late 50's. Due to the fact that there was a very limited supply, patients had to be diagnosed with a severe medical condition which would justify them to be able to receive growth hormone. These conditions included growth hormone deficiency, Turner Syndrome (this occurs only in females), Prader Willi syndrome and dwarfism to mention a few. It was found out later, however, that this type of treatment wasn't really safe. After one patient received a corneal transplant, he developed an infection and died as result of bacteria from the cadaver. This prompted scientists and doctors to make sure that anything extracted from a cadaver had to go through a purification process. Sadly, many patients who received growth hormone treatment prior to this process contracted Creutzfeldt Jakob Disease (CJD). This is a fatal disease that is the human form of mad cow disease. It causes the brain to turn into a sponge and can cause slurred speech, dizziness, and frequent losses of balance. Once the symptoms appear, it may only take a year to eighteen months before the patient succumbs to it. However, this disease can lie dormant in the system for almost thirty years. The patients who first received it in the sixties were now dying in the eighties. This is what led to the development of the synthetic form of human growth hormone in 1985 and put a halt to the earlier form of treatment. There have been no cases of CJD reported in patients that received HGH after the purification process in 1977, however.

Sadly, it seems that some French doctors didn't get the message that this form of treatment was no longer being used because of the dangers of acquiring CJD and they treated patients with the substance from the cadaver and consequently over one hundred patients died. Seven of them are now on trial for manslaughter and aggravated deception.

So far, side effects of children being treated with synthetic growth hormone are minimal, compared to children who were treated with pituitary derived growth hormone prior to 1985. According to Dr. Mary Lee, a contributing writer to the New England Journal Of Medicine, a review of safety data in numerous databases on over 100,000 children, there was really no increase of contracting any disease more than the rest of the population, perhaps with the exception of mild hypertension. Children receiving growth hormone prior to 1985 were at a risk of acquiring cancer and of course some did end up with CJD. However, it may be too early to tell what long term side effects may arise from the synthetic form of treatment.

Along the lines of psychosocial effects, it had been previously reported in studies that children of shorter stature experience more emotional distress; however those reports were unconfirmed. The National Institute of Health (NIH) did a controlled study of children with idiopathic short stature and found that their behavior was pretty normal and that growth hormone therapy did not really improve their lives too much. However, another recent report suggests that children who were treated with long term treatment had stable psychosocial functioning.

A 2006 study by two women from the University of Princeton also pointed to the fact that taller people were smarter, or might be perceived as such, which then explains why there is a pay disparity. However, the study conducted by Anne Chase and Christina Paxson mostly eluded to the fact that proper nutrition and a good socioeconomic environment were the key factors in contributing to someone's height, as well as genetics.

So therefore, it may not necessarily then be true that a taller person is smarter than a shorter person; though, sadly, they are perceived as such. So, taking growth hormone won't make someone smarter but apparently it will make someone look that way.

This study was a response to another study by other individuals. Professors from the University of Pennsylvania and University of Michigan arrived at the conclusion that persons earning power could be correlated with their height as an adolescent; especially for males. They stated that if a boy was tall at age sixteen, then he would more than likely have developed the confidence and the social skills to succeed in the labor market. Conversely, a short male at that same age would probably experience more social isolation and rejection and even if he were to grow at a later age, the treatment he received as an adolescent would adversely affect his confidence and therefore his potential to earn a substantial income.

Height seems to matter politically as well. With the exception of George Bush who triumphed over the taller (6'4") John Kerry in 2004, and Jimmy Carter who defeated Gerald Ford, the majority of the time the taller candidate will win. Our shortest president was James Madison (5'4"). Even Larry King suggested on his program on April 26th of 2007 that Dennis Kucinich would probably be a more viable candidate if he were 6'2". If this holds true, we can just go ahead and put Senator Barack Obama (6'1") in the White House; Hillary Clinton stands about 5'6" or so and John McCain stands about 5'9".

Is it no wonder that with how the taller are revered that parents want to opt for treatment for their children? If HGH is only made available to the more affluent in our society, how about the kids who are short but their families can't afford the treatment? Are they doomed? Will this create a bigger chasm between the rich and poor? Between the tall and short?

Women are so concerned with the height of their children that those who opt to seek artificial insemination demand that their sperm donors meet a certain height requirement. According to an article written by Christopher Wanjeck of Live Science, most sperm banks "draw the line at 5'11".

So, shortness is definitely stigmatized. Shorter men are seen as less mature, less intelligent and less masculine and any act of aggression is viewed as a complex on their part; so it's almost imperative that males don't end up too short. Yet, children who are treated with growth hormone will not grow to be 6'0" tall; they will still be shorter than the average adult.

The ABC news program 20/20 did a show last year on the subject of growth hormone and followed two adolescents through their treatment. One subject named Ryan, had been on the treatment for a few years and his height shot up to 5'6" at the age of 16. The other subject named Kaitlin, took the treatment for about a year and stopped because of the side effects. She grew to almost 5'0". However, David Sandberg of the State University of New York at Buffalo and Dr Jeffrey Bishop of the University of Exeter, who co-authored a study on the behavior of middle school students, said that the students didn't treat the shorter kids any differently than the taller ones and that growth hormone is overused and according to Dr Bishop could end up doing more harm than good. He says that taking a child to a doctor would do them more harm than good if they are healthy kids; you run the risk of stigmatizing them by telling them something is wrong with them.

Tam Fry, who is the chairman of the Child Growth Foundation, and has spent thirty years researching the issue (since his daughter was diagnosed with growth hormone deficiency) recommends that children get treatment early, as soon as a problem is discovered; however, he says also that giving a perfectly healthy child growth hormone is "totally inappropriate" and can cause the bones to fuse together much earlier than normal.

According to Professor Roderick Floud, who wrote the book Height, Health and History: Nutritional Status in the United Kingdom, 1750-1980, The best thing a parent can do is provide the child with adequate nutrition, exercise and a good home life. He says that "disease, warmth, comfort and even love can influence height."

According to a recent study conducted by Dr. Hau Liu, an endocrinologist at Stanford University, athletes who take growth hormone do not really increase their strength or muscle mass but they do have swelling in their muscle tissue and have higher lactic acid levels, which is a sign of muscle fatigue. So, if athletes have this condition, what of the children who have enough growth hormone and get it in excess? It can cause abnormal bone growth in the face and hands, high blood pressure and growth of excess hair.

According to an article from Drug Week in the summer of 2007, regarding acromegaly therapy, excess growth hormone can cause cardiac failure as a result of acromegaly and any growth hormone treatment should absolutely be stopped once the final height is achieved; though proper levels of growth hormone are needed to combat heart failure in adults.

Unfortunately, some parents can take it to the extreme with their children. A GP in London, named Al Jumaily, feared that her son (who was short but not short enough to qualify for treatment) might be bullied in school, used her position to inject her son with Genetropin. She was fined for deception and for the costs of the drugs and may lose her license to practice medicine.

Another pitfall of growth hormone therapy, especially in children with idiopathic short stature, is that puberty will set in sooner, causing the bones to fuse together at an earlier age and rob these children of an inch or two from their final heights. However, there is a treatment that can inhibit this process from taking place. Children taking Gonadotropin Releasing Hormone Agonist (GnRHa) can actually suppress their pubertal stage, while at the same time getting the maximum effect of their growth hormone treatment; this according to a study conducted by the Endocrine Society and published in the Journal of Clinical Endocrinology and Metabolism; there were no apparent side effects.

So, after reading about this issue, you can certainly see both sides of the argument. The parents and proponents are trying to do the best thing for these children in a society that prizes image and demonizes short stature, especially in boys. People lose out on all sorts of opportunities due to their short stature, however will these children really benefit from treatment? If they grow at all, it will be two or three inches at the most; it won't have a significant effect. They will still be short, parents will have spent at least $100,000 for about five years, there is no guarantee of any height gain and they may expose their children to arthritis and possibly oversized bones (acromegaly), which could lead to heart failure; possibly even cancer.

Maybe this says alot about how society views short stature, that parents are willing to give this treatment to their children. Let's say all these children who are receiving treatment respond positively and grow more than two or three inches; how about five inches? There will always be a group of people that are short and fall under a certain percentile. In ten to twenty years, will they then say that girls whose projected height is less then 5'2" should receive treatment then? Or males whose projected height is less than 5'6"? Then they will be taller than the previous group. Instead, maybe society should wake up and treat everyone equally and stop treating shortness as a disease that needs a cure. It's no different than telling a woman to get a sex change operation to achieve equality or telling an African-American to lighten their skin for better treatment. Height isn't a choice either and trying to alter this physical characteristic in a child can only send the wrong message that there is something wrong with the child, when change is really necessary in society's perception of people who exhibit differences.

Works Cited

Hall, Stephen S. Size Matters: How Height Affects the Health, Happiness and Success of Boys and the Men they Become Houghton Mifflin Co New York 2006

Sandel, Michael The Case Against Perfection Belknap Press, Cambridge Mass 2007

The Boston Globe "Does growth hormone improve strength and athletic performance": March 24, 2008

China Post "Doctor gives tips to growing teens" January 29, 2007

Daily Mail "The GP who gave her son growth hormone to beat bullies"; August 8, 2007

Drug Week "Acromegaly Therapy" July 13, 2007

Drug Week "Growth hormone deficiency" July 28, 2006

Drug Week "Hormone Therapy" November 17, 2006

Drug Week "Pediatrics: Growth Hormone is used to treat twice as many short boys than girls in the U.S. and Asia" May 2, 2008

The Guardian "French doctors on trial for CJD deaths after hormone "misuse": Manslaughter" February 7, 2008

The Herald (Glasgow) "A healthy height: does your child measure up?"; September 25, 2006

Irish Independent "Tall Order: When we were hunter-gatherers a man's height mattered, but does size really matter today?" August 21, 2007

The Journal of Clinical Endocrinology & Metabolism Vol 92 No 4 1402-1408

The New York Times "The Height of Success" November 5, 2006

Pediatrics "Growth hormone therapy for short stature: Is the benefit worth the burden?" David B. Allen MD Vol 118 No 1 July 2006

The Scotsman "It's no tall story, a few extra inches can make all the difference in life"; October 18, 2007

The Straits Times "Jabs to help kids grow taller"; January 14, 2007

USA Today "The debate is growing: Is being short a disability?"; November 13, 2006

The Washington Post "Human Growth Hormone Helps Small Kids Grow, But Some Call Its Wider Use Shortsighted" Cecilia Capuzzi Simon, September 30, 2003

20/20 ABC News Transcript "All men are not created equal" December 27, 1996

Ferring Pharmaceuticals Date accessed: 5/16/2008