M E TA - A N A LY S I S

Can we rely on adolescents to self-assess puberty

stage? A systematic review and meta-analysis

Susan C. Campisi,1,2 Josée D. Marchand,3 Fahad Javaid Siddiqui,1,4 Muhammad

Islam,1 Zulfiqar A. Bhutta,1,2,5 and Mark R. Palmert3,6
1
Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada;
2
Department of Nutritional Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada; 3Division

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of Endocrinology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; 4Health Services and
Systems Research, Duke-NUS Medical School, 169857, Singapore; 5Centre of Excellence in Women and
Child Health, The Aga Khan University South-Central Asia, 74000, East Africa & United Kingdom; and
6
Departments of Pediatrics and Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada

ORCiD numbers: 0000-0003-1072-9228 (S. C. Campisi); 0000-0002-9046-5105 (F. J. Siddiqui);

0000-0003-0637-599X (Z. A. Bhutta).

Context: Clinicians, researchers, and global health advocates often include pubertal
development in outcomes. However, assessments of pubertal stage can be challenging because
of the sensitive nature and feasibility of clinical examinations, especially in larger settings.

Objective: To determine the accuracy of self-assessed Tanner staging when compared with
physically assessed Tanner stages by a clinician.

Data Sources: MEDLINE, PubMed, Embase, Web of Science, Scopus, the Cochrane Library, CINAHL.

Study Selection: Studies were included if they reported 5 × 5 tables of self-assessment

compared to clinician–assessment for the 5-stage Tanner scale.

Data Extraction: We extracted data to generate complete 5 × 5 tables for each study, including
any subgroup eligible for the analysis, such as overweight/obese youth.

Data Synthesis: After screening, 22 studies representing 21,801 participants met our inclusion
criteria for the meta-analysis. Overall agreement was moderate or substantial between the 2
assessments, with breast stage 1, female pubic hair 1, male pubic hair 1, and male pubic hair 5
having the highest agreement. When stages were collapsed into pre- (Tanner stage 1), in (stages
2,3), and completing (stages 4,5) puberty, levels of agreement improved, especially for pre- and
completing pubertal development. Most included studies comprised Caucasian youth. More
studies are needed which include a broader range of geographic and socioeconomic settings, as
well as a greater diversity of racial/ethnic groups.

Conclusions: Self-assessment of puberty is most accurate when identifying Tanner stage 1,

Tanner stage 5 and when development is categorized into prepuberty, in, and completing
puberty phases. Use of self-assessment data should be structured accordingly. (J Clin Endocrinol
Metab 105: 2846–2856, 2020)

Protocol Registration: PROSPERO # CRD42018100205

Key Words: puberty assessment, systematic review, meta-analysis

ISSN Print 0021-972X ISSN Online 1945-7197

Printed in USA
© Endocrine Society 2020. All rights reserved. For permissions, please e-mail: journals.
permissions@oup.com
Received 11 December 2019. Accepted 11 March 2020. Abbreviations: B, female Tanner stage breast; BMI, body mass index; fPH, female pubic
First Published Online 16 March 2020. hair; G, male Tanner stage genitals; HCP, health care professional; mPH, male pubic hair
Corrected and Typeset 1 July 2020. 1–5; κ, Cohen’s kappa.

2846  J Clin Endocrinol Metab, August 2020, 105(8):2846–2856   https://academic.oup.com/jcemdoi:10.1210/clinem/dgaa135

doi:10.1210/clinem/dgaa135
M
onitoring a youth’s growth and pubertal develop-
ment is an important part of health surveillance
of an individual as well as a population. Abnormalities
of pubertal timing often represent the extreme ends of
the normal spectrum but can also be a manifestation of
an underlying disorder or poor nutritional status (1, 2).
Moreover, for those who have a known systemic illness,
assessments of growth and puberty are key indicators
of effective management. Knowledge of pubertal status
is also important in the assessment of some aspects
of physiology; for example, assessments of metabolic
status should consider the increasing insulin resistance
that accompanies the onset of puberty.
Interestingly, the age of puberty is now known to
associate with many later-life health outcomes in both
men and women. For example, negative impacts of pu-
bertal timing on the future health of women include an
association with a higher risk of breast cancer, cardio-
vascular disease, and metabolic disorders among those
with early puberty, whereas later puberty has been as-
sociated with increased risk of disorders such as celiac
disease and low bone mineral density (3–5). In men,
early puberty has been associated with increased risk
of cardiovascular disease and bipolar disorder in later
life, whereas later puberty has been associated with
anxiety, depression, asthma and eczema (4). These later
life associations have increased the need for a better
understanding of the factors that regulate the timing of
puberty, and support the need for ongoing assessments
of pubertal timing in the general population to monitor
trends toward earlier development.
For all of these reasons, health care providers,
including family doctors, general pediatricians, adoles-
cent medicine providers and pediatric subspecialists, as
well as epidemiologists and other researchers, require
the accurate assessment of pubertal timing to guide their
work. However, there are many challenges in obtaining
physical assessment data, including the reluctance of
youth to undergo examinations and the need for staff
to conduct assessments—issues that may be exacer-
bated in large population studies and studies requiring
serial evaluations. Lack of familiarity/expertise with the
examinations among providers and discrepancies be-
tween the sensitive nature of the assessment and local
cultural practices among families and youth represent
other barriers. These limitations often compel reliance
on results of self-assessments, but one wonders: are such
self-assessment results reliable?
To address this question, a systematic review and
meta-analysis was conducted to determine the agreement
between self-assessed and health care provider (HCP)
physically assessed Tanner staging. Here the results of
https://academic.oup.com/jcem  2847
this meta-analysis are reported, including subanalyses
of agreement for obese youth and self-assessment tools.
Methods
Using a 3-step search strategy, studies reporting the agree-
ment between Tanner staging conducted by an HCP (hereafter
referred to as HCP assessment) and self-assessed Tanner sta-
ging by adolescents were identified. An initial limited search of
PubMed was undertaken followed by an analysis of the text
words contained in the title and abstract, as well as the index
terms used to describe the articles. A second search using all
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identified keywords and index terms was then undertaken
across all included databases. The third step included scanning
the reference list of the identified articles to extract articles
not previously identified. The search strategy was developed
by S.C., J.M., and the Hospital for Sick Children librarian (6).
The searches were initially run on June 27, 2018, and updated
on December 19, 2018, in MEDLINE, PubMed, Embase, Web
of Science, Scopus, the Cochrane Library, and CINAHL and
are available here (6). Because of limited capacity within the
study for a translator, non-English titles were excluded. There
was no limit on the publication date or geographical location
for the inclusion of studies. The study protocol was registered
at PROSPERO #CRD42018100205.
Inclusion and exclusion criteria
Cohort and cross-sectional studies reporting participant
ages between 6 and 19 years were eligible. Participants with
or without disease, and studies reporting agreement for over-
weight and/or obese populations were also eligible. Studies
that recruited participants with disease conditions like cystic fi-
brosis, diabetes mellitus, and Crohn’s disease that are not likely
to impact participants’ ability to correctly assess their puberty
stage were eligible. Studies using any tool for self-assessment
of puberty were eligible. Inclusion in meta-analyses required
the studies to report a 5 × 5 table or other details from which
such tables could be constructed for Tanner stage breast (B)
1-5, Tanner stage genitals (G) 1-5, female pubic hair (fPH) 1-5,
or male pubic hair (mPH) 1-5. If study reports did not provide
the required data, the corresponding authors were contacted
twice and the missing data requested; however, no additional
data could be obtained. Studies of participants with cognitive
impairment were excluded, as were studies reporting puberty
in participants with body dysmorphic disorders such as anor-
exia because we believed the body dysmorphic nature of the
disorder would alter the participant’s ability to correctly assess
his or her puberty. As the focus was on youth self-assessment,
studies, where a parent or other adult assessed or assisted the
participant, were not included.
Reference standard and index test
Assessment of Tanner stages by either physician, nurse, or
other trained HCP was the reference standard. Tanner sta-
ging comprises indicators used to assess the development of
secondary sexual characteristics during puberty—breast and
pubic hair development in girls, and genital and pubic hair
development in boys. To allow for the direct comparison of
the index and reference tests, this systematic review adheres
2848  Campisi et al   Reliability of Self-assessed Puberty Stages
to a strict definition of Tanner staging (7, 8) that, for example,
does not include the assessment of testicular volume by Prader
orchidometer. The index test was self-assessed puberty staging
using Tanner criteria. Several self-assessment tools were used
in the included studies. All tools included an image with either
a photograph or line drawing, with or without an accom-
panying description. Most studies developed their self-assess-
ment tools based on the Morris and Udry (9) or Tanner (7, 8)
drawings; however, some designed their tools.
Study selection and data collection
Screening was conducted in duplicate (J.M. and S.C.) for
titles, abstracts, and full-text articles. All references were man-
aged in an EndNote v7.8 library and exported to Covidence
(10) online review software for study selection. Extraction
forms were designed a priori, and pilot tested (n = 5) by
J.M. and S.C. Post pilot, extraction forms were revised to
standardize extracted data. All data were extracted in dupli-
cate from the included studies by I.M., F.J.S., A.K., J.M., or
S.C. and then matched. Data extracted included: author, pub-
lication year, study design, sample size, type of recruitment
(prospective or retrospective), study population characteristics
and the clinical context; details of reference standard; index
test used, and data to generate 5 × 5 tables for breast, genital,
mPH, and fPH Tanner stages. Discrepancies were resolved by
consensus.
Assessment of methodological quality and risk
of bias
The methodological quality of each included study was as-
sessed using the Quality Assessment of Diagnostic Accuracy
Studies‐2 (11). The 4 domains assessed for risk of bias were
patient selection, index test, reference standard, and flow and
timing. Applicability concerns were assessed in the first 3 do-
mains. In each domain, the signaling questions were answered
with “yes,” “no,” or “unclear,” followed by a judgment of the
risk of bias as “low,” “high,” or “unclear” risk. Two review au-
thors (J.M. and S.C.) independently evaluated included studies
and resolved any disagreements by discussion, with referral to
a third review author as necessary.
Statistical analysis
To obtain Tanner stage-wise or puberty phase-wise Kappa
(κ) statistic for a given body part (ie, B, G, mPH, and fPH), we
transformed 5 × 5 tables from each study to stage-wise (stages
1-5) 2 × 2 tables or to phase-wise (pre-, in/early, and com-
pleting/late puberty) 2 × 2 tables. The 3 puberty phases reflect
a commonly used puberty phase (12) classification. Prepuberty
phase corresponded to Tanner stage 1, in/early puberty corres-
ponded to combined Tanner stages 2 and 3, and completing/
late puberty corresponded to combined Tanner stages 4 and
5. A κ statistic and 95% CI was calculated (13) stage-wise or
puberty phase-wise for female B, male G, mPH, and fPH for
each study. κ statistics then were meta-analyzed using random
effects model to obtain pooled κ estimates and corresponding
95% CI for each stage or phase.
To determine pooled estimates and corresponding 95%CI
for self-assessment overestimation or underestimation, we
first calculated the percent overestimation or under estimation
for each study for female B, male G, mPH, and fPH. Pooled
J Clin Endocrinol Metab, August 2020, 105(8):2846–2856
estimates and corresponding 95% CI were obtained by meta-
analysis using random effects model.
To determine the impact of different self-assessment tools
on agreement, a stratified analysis was conducted with the
tool as the variable using 5 × 5 tables for overall Tanner
stages (1-5) female B, male G, mPH, and fPH. The tool vari-
able was categorized into 4 categories: (a) line drawings
without descriptions, (b) line drawings with descriptions, (c)
photographs without descriptions, or (d) photographs with
descriptions. Pooled κ and linearly weighted κ w statistics
with corresponding 95% CI for each tool category were cal-
culated (13).
Because a body mass index (BMI) > 85th percentile can
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lead to confusion between adipose and breast tissue during
Tanner staging, the main analysis did not include these parti-
cipants. However, a separate analysis was conducted to com-
pare the agreement of studies reporting the self-assessment
results of adolescents who were overweight or obese with the
self-assessment results of youth with normal BMI. A κ statistic
and estimate were calculated as described previously.
Statistical heterogeneity was assessed by examining forest
plots across studies for the variability of study estimates and
overlap of the 95% CI. The percentage of variance in the
meta-analysis that was attributable to study heterogeneity
was calculated using I2 (14). I2 value greater than 75% sug-
gests substantial heterogeneity among the study’s κ statistics.
Therefore, a random-effects model was used to accommo-
date inherent high methodological heterogeneity and reduce
the impact of large studies on pooled κ estimates. A final κ
value of 0.21 to 0.40 was considered to be fair agreement be-
tween the physical examination assessment and the self-assess-
ment; 0.41 to 0.60 was considered to be moderate agreement;
0.61 to 0.80 was considered to be substantial agreement; and
greater than 0.81 to 0.99 to be almost perfect agreement (15).
All analyses were performed using STATA (v14.2).
Results
Our search identified 838 studies. After screening, 22
studies representing 21 801 participants (boys n = 9854
[45.2%] and girls n = 11 947 [54.8%]) contributed to
the meta-analysis as outlined in the PRISMA flowchart
(Fig. 1). Twenty studies (90%) reported agreement for
female B; 14 (64%) studies for male G; 19 (86%) studies
for fPH; 18 (82%) studies for mPH; the same number
of studies contributed to the analysis of collapsed pu-
berty phase (pre, in or early, and completing or late pu-
berty) analysis. It is also important to note the timing
and sequence of assessments. With regard to timing,
20 studies were cross-sectional with the self-assess-
ment and HCP assessment taking place immediately
following each other and 2 studies were prospective
with 1 study stating the time interval between assess-
ments as 1 week, and 1 study stated the time interval
as 2 weeks. Sequentially, self-assessment was conducted
before the HCP assessment in 16 studies, 5 of which
stated the HCP was blinded to the self-assessment score.
doi:10.1210/clinem/dgaa135
Figure 1. PRISMA flowchart of study selection.
Physical assessment was conducted before self-assess-
ment in 5 studies. One study stated that self-assessment
was conducted either before or after the HCP assess-
ment. Twenty studies recruited participants by conveni-
ence sampling (ie, from endocrinology clinics), 1 study
conducted consecutive recruitment, and 1 study used
random sampling. A single study of participants with
anorexia nervosa was excluded. As well, a single study
examined the reliability of the parent assessment in add-
ition to the reliability of the child assessment in com-
parison to HCP assessment. In this case, only the child
data were used for the meta-analysis and the parent
data were disregarded. Line drawings with description
were used to aid/guide the self-assessment in 12 (55%)
studies; line drawings alone in 5 (23%); photographs
alone in 2 (9%); photographs with a description in 2
(9%); and 1 study (5%) used photographs and line
drawings plus description (Table 1). Fifteen studies
(68%) were from high-income countries and 7 (32%)
from middle-income countries according to World Bank
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Income Groups. Using World Health Organization re-
gions, 12 studies (54.5%) were from the Region of the
Americas; 3 studies (13.6%) from the European Region;
3 studies (13.6%) from the Western Pacific Region; 2
studies (9.0%) from the South-East Asia Region; 1 study
(4.5%) from the African Region; and 1 study (4.5%)
from the Eastern Mediterranean Region.
The overall quality assessments of included studies
were high for applicability (patient selection, index test,
and reference standard) and for the risk of bias (index
test, reference standard, and flow and timing). Ratings
for the risk of bias pertaining to the patient selection for
13 (59%) studies indicated low risk of bias; 9 studies
(41%) were identified as “unclear risk.” Among those
with “unclear risk,” risk of bias was downgraded mostly
because participant selection was not random. Due
to the nature of the topic at hand, convenience sam-
ples, such as school settings or cross-sections of cohort
studies were reported in these studies (6). No studies
were excluded based on the risk-of-bias assessment.
Table 1. Characteristics of Included Studies
Health Professional
Publication Performing the Physical
Author Year Country Sample Size Age Range (years) Assessment Self-Assessment Tool
Boas et al (16) 1995 USA 61 12.0–18.9 Physician and nurse Photos (7,8) + description
Bonat et al (17) 2002 USA 244 12.9–15.5 Physician and nurse Line drawings + description
Brooks-Gunn et al (18) 1987 USA 85 11.0–13.0 Physician and nurse Line drawings
Chan et al (19) 2008 China 354 8.0–18.0 Other clinician Line drawings (9) + description
Chavarro et al (20) 2017 Mexico 245 8.0–13.0 Physician Line drawings + description
Desmangles et al (21) 2006 USA 240 6.0–16.0 Physician Photos (7,8)
Ernst et al (22) 2018 Denmark 197 13.7–16.6 Physician Line drawings + description
Hergenroeder et al (23) 1999 USA 107 8.0–17.0 Physician Line drawings + description
Jaruratansirikul et al (24) 2015 Thailand 1934 8.0–18.0 boys Physician Line drawings + description
2850  Campisi et al   Reliability of Self-assessed Puberty Stages

7.0–16.0 girls
Lamb et al (25) 2011 USA 232 8.0–18.0 Physician Line drawings
Lee et al (26) 2006 USA 67 8.0–18.0 Physician and nurse Line Drawings (9)
Leone et al (27) 2007 Canada 47 12.0–17.0 Physician Line drawings + description
Morris et al (9) 1980 USA 47 12.0–16.0 Physician Line drawings (9)
Norris et al (28) 2005 South Africa 182 10.0–18.0 Nurse Photographs (7,8) + line drawings (9)
+ description
Peng et al (29) 2018 China 174 8.0–18.0 Physician Photos (computer generated)
Rabbani et al (30) 2013 Iran 190 9.0–16.0 Physician Line drawings + description
Rasmussen et al (31) 2015 Denmark 868 7.4–14.9 Physician Line drawings + description
Rollof et al (32) 2012 Sweden 100 10.0–16.0 Nurse Line drawings + description
Schall et al (33) 2012 USA 100 8.0–18.0 Physician Line drawings + description
Stephen et al (34) 2008 USA 87 8.0–16.0 Physician Line drawings
Sun et al (35) 2012 China 16 046 8.0–18.9 Physician Line drawings + description
Wacharasindhu et al (36) 2002 Thailand 194 7.0–15.0 Physician Photos (7,8) + description
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doi:10.1210/clinem/dgaa135 https://academic.oup.com/jcem  2851

For females, we observed substantial agreement (κ
value: 61-80) for B 1 and fPH 1. Moderate agreement
(κ value: 41-60) was observed for B 2, B 4, B 5, fPH
2, fPH 3, and fPH 5. Fair agreement (κ value: 21-40)
was observed for B 3 and fPH 4. When broadening the
puberty criteria by using puberty phases (pre [Tanner
stage 1], early/in [Tanner stages 2-3], and late/com-
pleting [Tanner stages 4-5]), substantial agreement was
observed for prepuberty and completing puberty for
both B and fPH development and moderate agreement
for in puberty for both B and fPH (Fig. 2A).
observed for G 1, G 4, mPH 2, mPH 3, and mPH 4,
whereas a fair agreement was observed for G 2 and G
3. Again, we observed greater agreement when broad-
ening the puberty criteria by using puberty phases. For
boys, no significant differences were observed between
overweight/obese and nonobese studies for most genital
and mPH Tanner stages or puberty phases. Few excep-
tions to note are the significantly lower agreement for
G 2, G 5, mPH 2, and mPH 3 as well as pre- versus
in puberty phases for obese/overweight compared with
nonobese/overweight males. Substantial agreement was

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For males, substantial agreement was observed for observed for completing puberty for genital develop-
mPH 1, mPH 5, and G 5. Moderate agreement was ment, as well as prepuberty and completing puberty for

A. Female Pubertal Milestones

100

80 Substantial
Agreement
60
κ (95%CI)

Moderate
Agreement
40
Fair
Agreement
20

Breast Development (n=20 studies) Pubic Hair (n=19 studies)

B. Male Pubertal Milestones

100

80
Substantial
Agreement
60
κ (95%CI)

Moderate
Agreement
40
Fair
Agreement
20

Genital Development (n=14 studies) Pubic Hair (n=18 studies)

Abbreviations: n: number of studies used to calculate the pooled kappa estimate

Figure 2. Pooled Kappa estimates (κ) and 95% confidence intervals for self-assessed Tanner stages and puberty phases by sex.
2852  Campisi et al   Reliability of Self-assessed Puberty Stages
mPH development. Moderate agreement was observed
for prepuberty and in puberty for G development and in
puberty for mPH (Fig. 2B).
Girls and boys were equally likely to overestimate
their pubic hair and breast or genital stage as they were
to underestimate. The pooled estimates for overesti-
mation for fPH were 16.81(95% CI, 16.15-17.49); for
mPH were 15.36 (95% CI, 14.66-16.09); for B were
18.77 (95% CI, 18.08-19.48); and for G were 24.22
(95% CI, 23.32-25.14). Pooled estimates for underesti-
mation for fPH were 15.03 (95% CI, 14.39-15.68); for
mPH were 15.19 (95% CI, 14.49-15.91); for B were
14.88 (95% CI, 14.26-15.53); and for G were 18.44
(95% CI, 17.63 to 19.28).
Tools used for self-assessment varied. Eight studies
provided the citation for their images which was either
Morris and Udry (9) or Tanner (7, 8). The remaining
studies did not provide a citation; however, some did
provide a sample of their illustrations. In these cases, it
was obvious that they were using images derived dir-
ectly from Morris and Udry (9) or Tanner (7, 8) images.
Adding descriptions along with an image (either a line
drawing or photograph) led to a greater agreement be-
tween the self-assessment and HCP assessment for boys
and girls when overall Tanner staging was assessed.
Additionally, photographs lead to a significant improve-
ment in agreement over line drawings for boys (Fig. 3).
When specific stages and specific tools were assessed,
it was observed that line drawings derived from either
Morris and Udry (9) or Tanner (7, 8) were not different
in their ability to achieve greater agreement. However,
photos with description were superior for assessment of
breast development and mPH, whereas photos with or
without description performed best for fPH (6).
Only 2 included studies separately reported agree-
ment for overweight and/or obese participants (children
with BMI > 85th percentile) for breast development
and only one for each of the other physical characteris-
tics; however, these studies included large sample sizes
that allowed for a separate analysis (n = 3715; 54.6%
female). These limited data revealed no significant dif-
ference between the studies reporting the agreement
between obese/overweight and those reporting agree-
ment among nonobese/overweight participants for
breast, fPH Tanner stages and puberty phases, with CIs
that overlap. For boys, no significant differences were
observed between overweight/obese and nonobese
studies for most G and mPH Tanner Stages or puberty
phases. Few exceptions to note are the significantly
lower agreement for G 2, G 5, mPH 2 and mPH 3 as
well as pre- versus in puberty phases for obese/over-
weight compared with nonobese/overweight males (6).
J Clin Endocrinol Metab, August 2020, 105(8):2846–2856
Discussion
Individual studies have assessed the agreement between
self-assessed Tanner staging and the gold standard of as-
sessment by an HCP. A limited number of reports have
reviewed some of those data (37–41), but no previous
systematic review has used formal meta-analysis meth-
odology to quantify the agreement between pubertal
staging by self-assessment and that by physical exam-
ination or included as many studies. Our meta-analysis
comprised 22 studies encompassing a large number
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of participants (n = 21 801), including a significant
number of male participants (n = 9854), who are fre-
quently underrepresented in puberty research. These re-
sults provide important guidance on how self-assessed
Tanner staging may be implemented to enhance agree-
ment with HCP assessed Tanner staging.
Using currently available tools, self-reported assess-
ment of pubertal development is able to reasonably sep-
arate pubertal development into 3 phases: prepuberty,
in/early puberty (consisting of Tanner stages 2 and 3),
and completing/late puberty (consisting of Tanner stages
4 and 5) (12). Agreement decreased when comparing
individual Tanner stages between self-assessment and
examination, especially for stages 2, 3, and 4, likely re-
flecting the complexity of their evaluation. Most often, a
higher agreement was observed for pubic hair develop-
ment in both girls and boys, whereas girls appeared to
have a greater ability to discern breast stages compared
with the boys’ ability to discern genital stages. Perhaps
this difference between girls and boys is not surprising.
Assessment of genital Tanner stages in boys is complex
because it is based on size and general appearance,
which is possibly more subjective than the assessment
of breast stage, which relies more on structural aspects
of nipple/areola appearance (42). This subjectivity could
contribute to lower agreement between self and HCP
assessments. In terms of the tools used, our analysis re-
vealed increased agreement when the tool included an
image with an accompanying description rather than an
image alone.
Our results have several important practical implica-
tions. If investigators or clinicians require data regarding
individual Tanner stages, then it is likely better to obtain
those data via HCP examinations whenever possible.
On the other hand, if the variable of interest is whether
an individual is prepubertal or in-puberty vs completing
puberty, self-assessment may suffice. In scenarios such
as large epidemiology studies or global health initia-
tives that rely upon self-assessment, questions designed
to focus on phases of puberty as opposed to individual
stages may be more tractable and produce more reli-
able results. If using self-assessment, use of an image
doi:10.1210/clinem/dgaa135 https://academic.oup.com/jcem  2853

A. Self-Assessment Tool - Girls

100
n=2
n=3
n=2
n=10 n=3
Weighted Kappa (%) with 95%CI

80
n=4
n=11 Substantial
n=4 Agreement
60
Moderate
Agreement
40
Fair

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Agreement
20

0
Line Drawing Line Drawing with Description Photographs Photographs with Description
Breast Development Pubic Hair

B. Self-Assessment Tool - Boys

100

n=11 n=3 n=2

n=8
n=2
80
Weighted Kappa (%) with 95%CI

n=1
Substantial
n=2 Agreement
n=3

60
Moderate
Agreement
40
Fair
Agreement

20

0
Line Drawing Line Drawing with Description Photographs Photographs with Description

Genital Development Pubic Hair

Figure 3. Pooled weighted Kappa estimates (κ w) and 95% confidence intervals for self-assessment tools by sex.

with an accompanying description rather than an image at identifying the onset/progression of true puberty
alone will likely yield more accurate results, although it than boys.
is recognized that at times societal, cultural, or religious Another important question is whether self-assess-
factors may limit the use of images. Finally, one must ment can be used for evaluation of pubertal develop-
also remember that pubic hair alone is not necessarily ment among overweight and obese youth. Our results
indicative of central puberty (hypothalamic-pituitary- indicate that overweight/obese children may be able to
gonadal axis maturation) as the hair could derive from assess their puberty development as effectively as chil-
adrenarche instead of gonadarche. The difference in the dren with normal BMI with the exception of G 2, mPH
agreement between self vs HCP assessments of breast 2, mPH 3, and in puberty mPH in boys. Interestingly,
development compared with male genital development although much concern surrounds assessment of breast
suggest the possibility that girls may be more accurate development in females and the ability to distinguish
2854  Campisi et al   Reliability of Self-assessed Puberty Stages
true glandular tissue from adipose tissue, these re-
sults did not indicate that overweight/obese girls’ self-
assessments were more inaccurate than those made by
girls of normal weight. Although encouraging, these
results should be considered preliminary within this
subpopulation as they are limited to 1 or 2 studies. More
evidence including those from different geographic loca-
tions and ethnicities would increase the representative-
ness of these findings.
Our meta-analysis does have limitations. Although
physical examination is the gold standard for assessment
of the secondary sexual characteristics of puberty, some
have suggested that perhaps hormonal levels should in-
stead be a comparator (43–45). Current limitations for
the use of hormonal data exists, but more importantly,
hormonal levels conceptually address a slightly different
question than the one we asked regarding how accur-
ately youth can assess the physical stages of puberty.
In the studies we assessed, few details were provided
concerning the HCP’s level of training in pubertal as-
sessments, and we know that knowledge of pubertal
examinations and the confidence of the examiner can be
at quite variable levels (46). Differences in training and
proficiency of the HCP could allow for the introduction
of variation (inaccuracy) within the gold standard. In
overweight or obese patients, HCP training and experi-
ence is critical as it may be difficult to determine Tanner
stages in breast development (because of presence of
adipose tissue) and genital development (because of the
presence of a suprapubic fat pad). In terms of general-
izability, the majority of the included studies were com-
prised of Caucasian youth and were conducted within
high-income countries; as such, more studies from other
geographic and socioeconomic settings and including
a broader range of racial/ethnic groups are needed. As
none of the included studies were from low-income
countries, data from resource-constrained settings are
also needed because they would help inform the use of
self-assessment as part of global health initiatives. Last,
we identified no studies for inclusion in our analysis
that assessed the use of self-assessment among gender-
incongruent youth or among individuals with clinical
diagnoses of delayed or precocious puberty.
Having strict inclusion/exclusion criteria is an im-
portant component of a rigorous meta-analysis because
they allow for direct comparison of data across studies.
However, as a result of such criteria, not all published
studies involving the comparison of self-assessment of
pubertal development and physical examination were
included in our study. For example, we did not include
studies that used the Pubertal Development Scale (47)
because it only involves the use of text descriptions and
J Clin Endocrinol Metab, August 2020, 105(8):2846–2856
its categories do not align 1:1 with the 5 Tanner stages.
We also excluded studies reporting parent-assessed or
parent-assisted assessments instead of self-assessments
conducted by the adolescent independently because our
goal was to evaluate self-assessment. Inconsistent re-
sults regarding the correlation between parent reports
and physical examination warrant further examination
as a study by Rasmussen et al (31) reported that parents
tended to underestimate pubertal development, whereas
Dorn et al (48) reported a correlation ranging from
r = 0.75 to 0.87. Regardless, self-assessment is unlikely
Downloaded from https://academic.oup.com/jcem/article/105/8/2846/5807960 by guest on 07 January 2024
to be replaced by parent-assisted measures given the in-
creased desire for privacy as adolescents approach mid
puberty.
In addition, 16 studies were not included in the meta-
analysis as the reported agreement data were not in the
correct 5 × 5 format and no additional raw data were
received in response to letters to the authors. However,
an informal review of these 16 studies indicated that
their results are consistent with the results of our meta-
analysis. In addition, a recently published narrative re-
view examining methods of puberty assessment could
not formally assess the strength of agreement between
self- and HCP assessments, but the authors did highlight
a higher agreement for both sexes in the assessment of
pubic hair and lower agreement for male genital devel-
opment (38), consistent with our results.
Despite these limitations, our study has many
strengths. It addresses a question with implications
for individuals in many fields, including HCPs, those
conducting physiologic and genetic research, epidemi-
ologists, and global health workers. A rigorous method-
ology, as well as a large number of studies and youth,
are key assets of this meta-analysis. The results point to
practical actions regarding what data can be obtained
more reliably and the importance of using an image
with a description whenever feasible.
Conclusion
Our data indicate that when used to identify Tanner
stage 1 or 5 or to categorize pubertal development into
prepuberty, in/early puberty, or completing/late puberty,
self-assessment tools yield data that likely have substan-
tial agreement with data obtained from HCP examin-
ation. Depending on the research or clinical question
being asked, improved agreement in self-assessment
when using 3 puberty phases may be more useful than
the 5 Tanner stages. However, it is important to note
that there remains a potential for misclassification even
when using the 3-phase classification system. Using
tools that provide the most information (images and
doi:10.1210/clinem/dgaa135
descriptions) leads to results with the highest agreement
with the physical examination. Because the studies in
this meta-analysis used several different images and de-
scriptions, 1 area of future work is the generation of or
agreement regarding standard images and descriptions
to help minimize variation in self-assessment. The avail-
able data suggest that self-assessment data for over-
weight and obese youth may also be reliable, although
this is another area where further research is warranted.
In clinical or research settings where discrimination be-
tween Tanner stage 2, 3, or 4 is required, the physical
assessment remains paramount.
Acknowledgments
Thank you to Tamsin Adams-Webber for her assistance with
search strategy terms and translation of Medline search
strategy to other database platform command language.
Thank you also to Amirtha Karunakaran for assistance with
data collection.
Financial Support: Susan Campisi is supported by SickKids
Restracomp Doctoral Award. Josée Marchand was supported
by Health Canada through the Maternal-Infant Research
on Environmental Chemicals Study. There was no external
funding for this manuscript.
Author Contributions: S.C.C. conceptualized and de-
signed the study, developed the data collection instruments,
assisted with data collection, drafted the initial manuscript,
and reviewed and revised the manuscript. J. D. M. designed
the study, developed the data collection instruments, collected
data, drafted the initial manuscript, and reviewed and revised
the manuscript. F.J.S. laid out the statistical analysis plan, col-
lected data, drafted the initial manuscript, and reviewed and
revised the manuscript. M.I. collected data, performed the
statistical analysis, and reviewed the manuscript. M.R.P. and
Z.A.B. provided senior supervision for the study, assisted with
interpretation of the results, and reviewed and revised the final
manuscript. All authors approved the final manuscript as sub-
mitted.
Clinical Trial Registration: PROSPERO # CRD42018100205
Additional Information
Correspondence: Susan C. Campisi, MHSc, PhD Candidate,
University of Toronto, Department of Nutritional Sciences,
Centre for Global Child Health, Hospital for Sick Children,
686 Bay Street, 11th Floor, Suite 11.9805, Toronto, Ontario,
M5G 0A4 Canada. E-mail: susan.campisi@sickkids.ca.
Disclosure Summary: S.C.C., J.D.M., F.J.S., M.I., and
Z.A.B. have nothing to declare. M.R.P. receives royalties from
UpToDate for having coauthored 2 chapters related to the
evaluation and treatment of precocious puberty.
Data Availability: Datasets generated during and/or ana-
lyzed during the current study are not publicly available but are
available from the corresponding author on reasonable request
https://academic.oup.com/jcem  2855
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