The Height of Popularity
Should human variability be treated as a medical problem?
by Peter Conrad
“One pill makes you larger, and one pill makes you small ...” — Jefferson Airplane
ADHD. PMS. Erectile dysfunction, menopause, anxiety and excessive shyness. The list of pharmaceutically treated human conditions underscores the drug industry’s insatiable appetite for new markets and reflects growing consumer demand to surmount some of life’s innate variability through medical treatment.
Over the past three decades, the creeping medicalization of human conditions — the process by which nonmedical problems are defined and treated as medical issues — has taken root. In recent years we have seen the medicalization of ADHD, various addictions, infertility, normal sadness, PTSD and obesity, among other conditions.
Starting in the late 1990s, direct-to-consumer television advertising helped speed this process. “Ask your doctor if Viagra … or Zoloft … or Strattera is right for you” has become a memorable marketing mantra encouraging consumers to push for treatment decisions that bypass traditional physician prerogatives. But one historical example that dates back to long before the FDA allowed drug companies to engage consumers directly provides a poignant reminder of the height to which unchecked medicalization can lead.
Between 1950 and 1970, parents and physicians worried about the social difficulties of girls with a predicted height of 5'10" or taller. They feared that their “too tall” girls would be awkward and self-conscious. In 1963, a medical endocrinologist wrote that tall girls “may find it difficult to attract male companions” and warned, “These girls frequently develop severe psychosomatic inferiorities.” Others fretted that such girls would have trouble finding “smart clothes.”
In this era, pediatric endocrinologists treated many girls with predicted heights over 5'10", but with normal estrogen levels, by prescribing yet more estrogen (including the synthetic estrogen DES) to bring on menses and close growth plates in bones to suppress height. Various studies showed an average of 1.5-to-2-inch reduction in predicted height, with some greater reductions. In their recent book “Normal at Any Cost,” medical journalists Susan Cohen and Christine Cosgrove suggest that doctors thought they were treating a disease — excess height — and preventing emotional suffering.
By the late 1970s, medical height suppression for girls faded as the cancer and infertility risks of supplemental estrogen and especially DES became better known. But the social reasons for the decline in these drugs’ use are even more telling. First, the rising feminist movement, with its ethic to accept women for who they are, discouraged the drugs’ continued use. Second, existing height restrictions for women’s employment (as flight attendants, as models, and in the military, for example) were removed. Third, and perhaps most significant, Title IX passed, requiring federally funded educational institutions to increase women’s participation in sports. With the opportunity to play basketball, volleyball and other sports, height enhanced girls’ social value; once a social liability, being tall was suddenly an athletic asset. Growth suppression in girls was demedicalized and became a very uncommon treatment.
Concern about boys’ height was almost a mirror image. Here parents and doctors worried that some boys wouldn’t grow tall enough. Evidence suggests that shortness in men can be a social disability: On average, taller men earn more money, get more promotions, are more likely to win presidential elections, have a bigger choice of mates and so forth. Short men (below 5'4") may suffer from the prejudice of heightism and be stigmatized as “shrimps” and “short stuff.” However, extracted growth hormone (GH), used to treat dwarfism and growth hormone deficiency, was difficult to obtain and extremely expensive. By 1985, it was known to increase the risk for Creutzfeldt-Jakob disease (similar to mad cow disease) and was banned.
Meanwhile, pharmaceutical giant Genentech had been working on a synthetic human growth hormone (HGH) for 10 years when it developed a safe substitute, Protropin. The FDA approved Protropin in 1985 for hypopituitary dwarfism and GH deficiency, targeting a small market of probably a few thousand children each year. But, as with many drugs, physicians could prescribe HGH off label to any children they felt could benefit from it, even if their condition did not fall within the prescription guidelines. And they did.
Physicians turned to HGH to treat idiopathic short stature (ISS), typically a predicted height below 5'3" for boys and 4'11" for girls. These children are short but have normal GH production. Industry critics and the FDA accused Genentech of covertly marketing Protropin for healthy short kids over more than a decade, and the agency prosecuted Genentech for illegally promoting Protropin. In 1995, Genentech paid a $50 million fine.
Physicians can still prescribe HGH for ISS when there is concern about a child’s potential adult height. The cost of treatment over five years for prepubescent boys is about $100,000 (not covered by health insurance) and the average increased growth is about two inches, for a cost of $50,000 an inch. HGH doesn’t make short people tall; it makes them less short. In 2003 the FDA approved Eli Lilly and Company’s HGH Humatrope for children in the lowest 1.2 percentile without GH deficiency. Lilly estimated 400,000 would be eligible, but, due to access and cost, only 10 percent would receive treatment. A half century after height became the focus of medical enhancement, stature is a resurgent target of medicalization.
Height is by no means the only condition that can be enhanced through biomedical intervention. With all the investment in medically beneficial drugs for Alzheimer’s disease, we can expect these same drugs to be promoted for individuals with memory capabilities in the normal range who desire an enhanced memory, perhaps under the guise of treatment for something like “memory deficit disorder” (which doesn’t yet exist). In fact, we may be at the dawn of an era where cosmetic endocrinology might, for better or worse, facilitate biomedical changes in our appearance or our abilities. The pharmaceutical companies are always ready to find new markets for their products, so it will require vigilance to weigh the social and medical risks inherent in these kinds of interventions.
Peter Conrad is the Harry Coplan Professor of Social Sciences and author of “The Medicalization of Society: On the Transformation of Human Conditions Into Medical Disorders” (Johns Hopkins University Press).