Tagged Women and Girls

Meet the Super Flasher: Some Menopausal Women Suffer Years of Hot Flashes

Kim Murton

What kind of hot flasher are you?

The hot flash — that sudden feeling of warmth that can leave a woman flushed and drenched in sweat — has long been considered the defining symptom of menopause. But new research shows that the timing and duration of hot flashes can vary significantly from woman to woman, and that women appear to fall evenly into four hot-flash categories.

Some women, called “early onset” hot flashers, begin to experience hot flashes long before menopause. Symptoms can begin five to 10 years before a woman’s last period, but the symptoms stop with the end of the menstrual cycle.

Then there are women who don’t experience their first hot flash until after menopause, the “late onset” hot flasher. And some women fall into a group the researchers called the “lucky few.” Some of these women never experience a single hot flash, whereas others briefly suffer only a few flashes when they stop menstruating.

And then there are the “super flashers.” This unlucky group includes one in four midlife women. The super flasher begins to experience hot flashes relatively early in life, similar to the early onset group. But her unpleasant symptoms continue well past menopause, like those in the late onset group. Her symptoms can last 20 years or more.

The findings come from the Study of Women’s Health Across the Nation, or SWAN, a 22-year-old study that has been tracking the physical, biological and psychological health of 3,302 women from a variety of racial and ethnic backgrounds. The study is being conducted at seven research centers around the country and is paid for by the National Institutes of Health.

“It explodes our typical myth around hot flashes, that they just last for a few years and everyone follows the same pattern,” said Rebecca Thurston, the senior author and a professor of psychiatry and epidemiologist at the University of Pittsburgh. “We may be able to better help women once we know in what category they are more likely to fall.”

That includes women like Lynn Moran, a 70-year-old retired financial planning assistant who lives near Pittsburgh and falls into the “super flasher” category. She remembers having her first hot flash around the age of 47. While the symptoms were subtle at first, soon the hot flashes became more bothersome. “It was enough to wake me up out of a sound sleep,” she said. “I wasn’t sleeping well because they were coming all night long and during the day. I was just miserable.”

Ms. Moran began hormone therapy, which helped but did not eliminate the symptoms. But when medical studies began to show health risks associated with the treatment, her doctor advised her to stop using hormones. She waited another 18 months until she retired, then stopped taking hormones in 2005.

The hot flashes “came back with a vengeance” and haven’t stopped since.

“I still have them. I still laugh about them,” she said, noting that she may experience several hot flashes a day. “I’ll be trying to get ready to go somewhere, curling my hair and have to redo everything and dry my hair again because I’ll be drenched. My makeup will literally run down my face. Here I am, 70 years old, complaining of hot flashes.”

Dr. Thurston notes that understanding variations on hot flashes is important to understanding women’s health in midlife. A 2012 study, published in the journal Obstetrics and Gynecology, suggested that the timing and duration of hot flashes may be an indicator of a woman’s cardiovascular health. The study found that frequent hot flashes were associated with higher cholesterol markers, particularly in thin women.

The latest findings from the SWAN study identified some patterns around the four subsets of women who experienced varying degrees of hot flashes. Women were distributed about equally among the groups, meaning 75 percent of women experienced some degree of hot flashes, while only 25 percent escaped the symptom.

Women in the early onset group were more likely to be white and obese. Women in the late onset group tended to be smokers. The lucky few women who had no hot flashes or only a few were more often Asian women and women in better health. The super flashers were more likely to be African-American, to be in poorer health and to consume alcohol. But the researchers cautioned that while they identified some statistical trends in each group, it’s important to note that each subset of hot flashers included a variety of women representing all races, ethnicities, body weights and health categories. No one factor appeared to determine a woman’s risk for any hot flash category.

For instance, while African-American women were three times as likely to be in the super flashers group, they represented only 40 percent of that group. The remaining 60 percent were white women, some Asian women and other groups.

Dr. Thurston said it is important that doctors understand that 75 percent of women have hot flashes in midlife and that they persist in at least one in four..

“It flies in the face of the traditional wisdom that women have these symptoms for three to five years around the final menstrual period,” she said. “We now know that is patently wrong.”

With Coercive Control, the Abuse Is Psychological

Maggie Chiang

Lisa Fontes’s ex-boyfriend never punched her, or pulled her hair. But he hacked into her computer, and installed a spy cam in her bedroom, and subtly distanced her from her friends and family.

Still, she didn’t think she was a victim of domestic abuse. “I had no way to understand this relationship except it was a bad relationship,” said Dr. Fontes, 54, who teaches adult education at the University of Massachusetts, Amherst.

It was only after doing research on emotional abuse that she discovered a name for what she experienced: Coercive control, a pattern of behavior that some people — usually but not always men — employ to dominate their partners. Coercive control describes an ongoing and multipronged strategy, with tactics that include manipulation, humiliation, isolation, financial abuse, stalking, gaslighting and sometimes physical or sexual abuse.

“The number of abusive behaviors don’t matter so much as the degree,” said Dr. Fontes, the author of “Invisible Chains: Overcoming Coercive Control in Your Intimate Relationship.” “One woman told me her husband didn’t want her to sleep on her back. She had to pack the shopping cart a certain way, wear her clothes a certain way, wash herself in the shower in a certain order.”

While the term “coercive control” isn’t widely known in the United States, the concept of nonphysical forms of mistreatment as a kind of domestic abuse is gaining recognition. In May, the hashtag #MaybeHeDoesntHitYou took off on Twitter, with users sharing their own stories.

Last December, England and Wales expanded the definition of domestic abuse to include “coercive and controlling behavior in an intimate or family relationship,” making it a criminal offense carrying a maximum sentence of five years. To date, at least four men have been sentenced under the new law.

“In this approach, many acts that had been treated as low-level misdemeanors or not treated as offenses at all are considered as part of a single course of serious criminal conduct,” said Evan Stark, a forensic social worker and professor emeritus at Rutgers University, whose work helped shaped the new law in England and Wales.

Dr. Stark, the author of “Coercive Control,” noted that the English law pertains to a course of conduct over time. American law still does not address coercive control; it deals only with episodes of assault, and mainly protects women who have been subjected to physical attacks. But in about 20 percent of domestic violence cases there is no bodily harm, he said.

Coercive control often escalates to spousal physical violence, as a 2010 study in The Journal of Interpersonal Violence found. “Control is really the issue,” said Connie Beck, a co-author of the study and an associate professor of psychology at the University of Arizona. “If you can control a person’s basic liberties verbally — where they go, who they see, what they do — you do not necessarily have to hit them regularly, but if a person is not complying, then often physical abuse escalates.”

To a victim of coercive control, a threat might be misinterpreted as love, especially in the early stages of a relationship, or when one is feeling especially vulnerable.

Dr. Fontes, for example, was in her 40s and newly divorced when she met her ex-boyfriend. He was charming and adoring, and though he was a little obsessive, she overlooked it. Never mind that she has a Ph.D. in counseling psychology, and specializes in child abuse and violence against women.

“For a person looking for love and romance, it can feel wonderful that someone wants to monopolize your time,” she admitted.

For Rachel G., 46, a mother of three who lives outside Boston (she didn’t want her full name used to protect her privacy), the manipulation was all-consuming. Her ex-husband made them share a toothbrush, and wouldn’t let her shut the bathroom door — ever. He set up cameras around the house, and fastened a GPS in her car to track her movements. Sometimes he would show up at her work unannounced, “always framed as him needing to know where I was in case the kids needed me, or because he missed me and wanted to see me, but it was just his way of regulating my behavior.”

She was miserable, but stuck it out for 18 years. It never occurred to her to leave: She had three children, and “he had convinced me that I would be unhappy anywhere,” said Ms. G., who does fund-raising for a nonprofit. “I wasn’t only a bad wife — in every respect — but I was a negligent mother, or an overbearing mother, I was unsupportive of him, I was a bad cook, I prioritized work over family, my family liked him better than me, our friends liked him better than me. The worse I felt about myself and doubted myself and internalized his view of me and the way the world should work, the more submissive and accommodating I became.”

In the end, it was he, not she, who filed for divorce, after catching her in an extramarital affair. She is not proud of her actions, but she is grateful it got her out of the relationship. “I would never have left if he hadn’t filed,” she said. “I was afraid.” Since then, she has been trying to re-establish connections with family members and friends.

Dr. Fontes ultimately left her partner after four years. The decision came after she spent two weeks away from him, and realized how diminished she had become. “There were repeated telephone calls and emails every day, but it was such a relief to wake up and go to sleep without having to check in with this other person,” she said. “I recovered a sense of who I was as a separated person, my own opinions, my own perspective.”

Most Women Prefer to Go Bare, Citing Hygiene (and Baffling Doctors)

Rachel Dratch, as customer, Nia Vardalos as spa technician during “Bikini Wax” skit on November 9, 2002. Sixty-two percent of a nationally representative sample of 3,316 women said they opted for complete removal of their pubic hair; 84 percent reported some grooming.

Rachel Dratch, as customer, Nia Vardalos as spa technician during “Bikini Wax” skit on November 9, 2002. Sixty-two percent of a nationally representative sample of 3,316 women said they opted for complete removal of their pubic hair; 84 percent reported some grooming. Dana Edelson/NBC, via Getty Images)

For years, gynecologists have had a bird’s-eye view on a phenomenon that is now so popular as to be almost commonplace: female genitalia, bereft of hair.

Sometimes called “grooming,” the practice of shearing off pubic hair — parodied on Saturday Night Live, celebrated as a girl-bonding ritual by various “Real Housewives” — has prompted sexual health experts to ask what motivates women to do it.

A new study published in the journal JAMA Dermatology on Wednesday confirmed just how widespread the practice is. Sixty-two percent of a nationally representative sample of 3,316 women said they opted for complete removal of their pubic hair; 84 percent reported some grooming.

But while previous research showed that women groom to facilitate sexual activity, this survey found the overwhelming majority said they did so for hygiene.

That perception troubled researchers. “Many women think they are dirty and unclean if they haven’t groomed,” said Dr. Tami S. Rowen, an obstetrician-gynecologist and the lead author of the study.

The study found that the practice crossed all ages and races. But the women most inclined to groom are younger, between the ages of 18 and 34. They were more likely to be white, with at least some college education. The researchers did not find associations between grooming and income or marital status.

Anecdotally, gynecologists say they are seeing girls as young as 13 take up grooming, when they have only recently come into puberty. The teenagers, doctors said, are influenced by locker room jeers, social media chatter, and even internet pornography, where female genitalia is often displayed as hairless and almost prepubescent.

“At least once a week I hear from a young woman that she thinks it’s wrong to have pubic hair, that it’s meant to be removed,” said Dr. Jennifer Gunter, who specializes in pelvic pain and vulvovaginal disorders for Kaiser Permanente Northern California. “Grooming has become so common that people think that’s the norm.”

Pubic hair functions as a protective cushion for sensitive skin, and has its own hygienic purpose, trapping bacteria from entering the vaginal opening. ”Prepubertal girls have a higher incidence of irritation because they don’t have that protection,” Dr. Gunter said.

Dr. Rowen, an assistant professor at the University of California San Francisco School of Medicine, is concerned about grooming’s prevalence both because of a spate of health problems linked to it, and because of what it may suggest about women’s self-image.

She and other doctors have seen grooming-related cases of folliculitis, abscesses, lacerations, allergic reactions to waxing burns, as well as vulvar and vaginal infections. One study has noted that 3 percent of ER visits for genitourinary trauma are a result of grooming.

Although some researchers speculate that micro-abrasions and nicks from grooming may facilitate the spread of sexually transmitted infections, no large studies have definitively made that connection. A paper from one clinic did note, however, the rise in the number of so-called Brazilian waxes among patients (men as well as women) and a concurrent decline in pubic hair lice.

But it was this study’s finding that women associate grooming with health and hygiene — many said they groomed before a visit to a health care provider — that disturbs many gynecologists. Women were self-conscious even in private, medical settings.

“I’ve had women say, ‘I’m sorry I didn’t get a chance to clean up down there,’” said Dr. Cheryl B. Iglesia, a professor of obstetrics-gynecology and urology at Georgetown University School of Medicine.

Emphasizing that pubic hair patterns vary widely, according to women’s stages of development, ethnicity and individuality, Dr. Iglesia eschewed the popularity of the narrow standard of what she calls “the Barbie doll look.”

The results of this study are part of a larger project looking at grooming by men as well as women, exploring demographics, motivation, perceptions, sexual behavior and health habits.

Women were more likely to groom if their partner expressed a preference for it, the study found. But while earlier smaller studies had shown a link between grooming and sexual activity, particularly oral sex, this study found that while some women groomed for that purpose, it was not the primary reason: For example, 22 percent of the women reported grooming around the area of the anus, but only 10 percent had partaken in anally-related sexual activity in the prior year.

Instead, the researchers said, providers of health care and aesthetic treatments should become attuned to the diversity of reasons that women groom. The women also said they did so for vacation and because they see their own genitalia as more attractive when groomed.

“If it is something you do for you and makes you feel better, awesome,” Dr. Gunter said.

But noting that 59 percent of the survey’s responders said they groomed for hygienic reasons, she added, “But don’t tell yourself it’s healthy or better from a medical standpoint.”

Pelvic Exams May Not Prolong Life, a Task Force Says

Stuart Bradford

Many women dread the indignity of the annual pelvic exam, in which they are poked and prodded with their feet in stirrups.

Now an influential government task force says there isn’t evidence that routine pelvic exams are necessary or prolong a woman’s life. Some experts think they may even do more harm than good.

And although some 60 million pelvic exams are done each year, the practice hasn’t been studied much. The United States Preventive Services Task Force, a panel of experts in preventative and primary care, declared today that the current evidence is “insufficient” to assess the balance of benefits and harms of the pelvic exam. The task force performed an exhaustive search of the medical literature published over the past 60 years and located only eight studies looking at the diagnostic accuracy of pelvic exams for just four medical conditions.

“We can’t make a recommendation one way or the other at this time,” said Dr. Maureen Phipps, the chairwoman of obstetrics and gynecology at Brown University’s Warren Alpert Medical School and a member of the task force. “We need more evidence.”

The finding refers only to the practice of routine pelvic exams for healthy women, and does not apply to women who are pregnant or those with existing conditions or symptoms that need to be evaluated.

“This is not a recommendation against doing the exam,” Dr. Phipps emphasized. “This is a recommendation to call for more research to figure out the benefits and harms associated with screening pelvic exams. That’s the big message here.”

This is the first time the Preventive Services Task Force has turned its attention to pelvic examinations, which can include a visual exam of external genitalia, an internal exam using a speculum, manual palpation to check the shape and size of the uterus, ovaries and fallopian tubes, and the simultaneous palpation of the rectum and vagina using lubricated gloves.

The recommendations about pelvic exams do not change current guidelines for cervical cancer screening, in which cells are collected from the surface of the cervix and vagina. The screening test is recommended every three years for women ages 21 to 29 and every five years for ages 30 to 65.

Pelvic exams have been subjected to quite a bit of scrutiny in recent years, possibly because of turf battles between physicians and reimbursement battles with insurers. The exams can be both time-consuming and expensive, in part because doctors are advised to have a chaperone present during the exam.

In 2014, the American College of Physicians told doctors to stop performing routine pelvic exams as part of a physical, saying there is no evidence they are useful and much evidence to suggest they can provoke fear, anxiety and pain in women, especially those who have suffered sexual abuse or other trauma.

The American Academy of Family Physicians endorsed that recommendation. But the American College of Obstetricians and Gynecologists (ACOG) continues to recommend an annual pelvic examination for women 21 and older, while acknowledging a dearth of data. Its Well-Woman Task Force, which was convened in 2015, recommended annual external exams but said internal speculum and bimanual exams for women without specific complaints or symptoms should be “a shared, informed decision between the patient and provider.”

“No woman should ever be coerced into having an exam, and that discussion should take place in a nonexam room environment, while the woman is fully dressed and sitting at equal level with the provider at a round table, without a desk between them,” said Dr. Barbara S. Levy, vice president for health policy at ACOG.

But Dr. Levy says that the exams should not be scrapped because trials – which would be difficult to design and fund — have not been carried out.

“I think there’s tremendous value in the laying on of hands,” Dr. Levy said. “Touch has a lot to do with establishing trust, and there are many things I can pick up on during a pelvic exam because I’m skilled and trained.”

She may pick up on the fact that a woman is experiencing abuse or domestic violence, or discover that a woman may benefit from interventions to strengthen muscles to prevent urinary incontinence down the line, she said, adding, “This is the art of medicine.”

Most obstetrician-gynecologists do routine pelvic exams, as do many other physicians, and the majority of preventive care visits between 2008 and 2010 included one, according to the task force’s report.

Health care providers say they can pick up on myriad gynecologic conditions during a pelvic exam, including cancers of the cervix, vagina, vulva, ovaries and endometrium, sexually transmitted diseases, genital warts and genital herpes, uterine fibroids, ovarian cysts and more.

But the task force found no studies that assessed how effective the exams are for reducing death and disease. So for example, although a pelvic exam might be useful in detecting ovarian cancer, the disease is relatively rare, so exams often result in false-positives that can lead to unnecessary surgery, the report said.

In four ovarian cancer screening studies with over 26,000 screened patients, more than 96 percent of the positive test results were false positives, meaning there was no real disease and many patients had unnecessary follow-up procedures.

But Dr. Levy said the call for more research is impractical. Exams are part of preventive care that is tricky to evaluate or assess, she said, and such studies are unlikely to get funded. “Looking for evidence-based answers to centuries-old processes and procedures doesn’t always make sense,” she said.

Putting Breast Cancer on a Diet

Linda Guinee, 60, a survivor of breast cancer, particpated in an earlier trial to see if weight-loss could improve her outcome. She lost 15 pounds and increase her physical activity.

Linda Guinee, 60, a survivor of breast cancer, particpated in an earlier trial to see if weight-loss could improve her outcome. She lost 15 pounds and increase her physical activity. Shiho Fukada for The New York Times

Should weight loss be prescribed as a treatment for breast cancer?

Scientists are recruiting thousands of women for a large clinical trial to find out. The plan is to put heavy women age 18 and older who were recently given diagnoses of breast cancer on diets to see if losing weight will keep their cancer from coming back.

“We have been telling women to do this for years, but we don’t really have definitive proof,” said Dr. Jennifer Ligibel, the principal investigator of the Breast Cancer Weight Loss study, who is a breast oncologist in the Susan F. Smith Center for Women’s Cancers at Dana-Farber Cancer Institute in Boston.

“If it shows that losing weight by increasing physical activity and reducing calories improves survival, weight loss and physical activity could become a standard part of treatment for millions of breast cancer patients around the world,” Dr. Ligibel said.

In a sense, the clinical trial is long overdue. Once a woman is given a breast cancer diagnosis, obesity is associated with a higher risk for recurrence and lower likelihood of survival in women of all ages, Dr. Ligibel said.

Studies showing that obese and overweight women are more likely to die of their breast cancer date back decades. Just two years ago, a meta-analysis crunched the numbers from more than 80 studies involving more than 200,000 women with breast cancer, and reported that women who were obese when diagnosed had a 41 percent greater risk of death, while women who were overweight but whose body mass index was under 30 had a 7 percent greater risk.

But while those studies showed an association between weight and breast cancer mortality, they weren’t designed to find out if weight loss after diagnosis improves survival or reduces the chance of a recurrence.

“Nobody understands biologically why that is,” Dr. Ligibel said, adding that researchers will be collecting blood samples throughout the trial to track metabolic changes that occur with weight loss. Exercise is also part of the program, and participants will work with health coaches. Fitbit is donating all the products that will be used to track their activity and weight.

The researchers will look at markers of inflammation and metabolism, including levels of insulin, insulinlike growth factor and hormones that regulate fat storage.

“There’s a physiology of obesity that happens in everybody, but many of the changes we see in obesity actually are factors that influence the growth of cancer,” said Dr. Pamela Goodwin, one of the study’s investigators and a professor of medicine at Mount Sinai Hospital in Toronto.

These changes include higher insulin and glucose levels, inflammation and an increase in certain proteins, all of which appear to fuel cancer growth, Dr. Goodwin said.

Obesity “makes a great environment for cancer to get a foothold and progress,” said Barbara Gower, a professor of nutrition at the University of Alabama at Birmingham, who is running a small short-term trial to see what happens when women with ovarian cancer remove all sugar and starches from their diet. “The hormonal messages getting through to cancer cells are that it’s a good time to grow, and the nutrition they need is there, too.”

While a drug may target one of the factors, Dr. Ligibel said, weight loss and exercise may be a more powerful intervention because they lead to a combination of changes. “You have something that can potentially change all of them to a metabolically healthy low inflammatory state,” Dr. Ligibel said.

The trial, which will get underway this summer, will cost an estimated $15 million to $20 million. It’s sponsored by the National Cancer Institute and the Alliance for Clinical Trials in Oncology.

Researchers are recruiting 3,200 women from across the United States and Canada who have a recent diagnosis of Stage 2 or Stage 3 breast cancer. Participants must be overweight, with a body mass index of at least 27, and have hormone receptor positive or triple negative tumors. (Women with another type of breast cancer, known as HER2-positive, will not be included because their prognosis does not appear to be associated with weight, researchers said.)

Participants must be 18 but there is no upper age limit, though they must be able to walk “a couple of city blocks and have a life expectancy of at least five years for other causes,” Dr. Ligibel said.

Volunteers will be randomly assigned to either a telephone-based weight loss program or to a control group for comparison. The goal for those in the intervention is to lose 10 percent of their body weight over two years. Participants will continue to be followed for 10 years to see whether their cancer progresses or not.

Weight loss is challenging, and some cancer treatments cause weight gain. But an earlier trial that tested a similar telephone-based weight loss intervention on a smaller scale found that women with breast cancer lost 4 to 5 percent of their body weight, Dr. Goodwin said.

“Breast cancer is a teachable moment,” she added.

The new trial might help doctors identify which patients will benefit most from losing weight, and whether even moderate weight loss is helpful, said Dr. Clifford Hudis, the new chief executive officer of the American Society of Clinical Oncology and former chief of Memorial Sloan Kettering Cancer Center’s breast medicine service, who was involved in the design of the Breast Cancer Weight Loss trial.

“If I tell patients they need to lose 20 pounds, they just roll their eyes and say it’s impossible,” Dr. Hudis said. “But if we could say they only need to lose 3 percent of their body weight, that wouldn’t be so scary. That’s more manageable.”

Disney Princesses Do Change Girls — and Boys, Too

Chang W. Lee/The New York Times

When you’re a parent of children of a certain age, the Disney princesses seem to be everywhere. For years, parents have been questioning how princess culture might influence little girls, particularly those who seem besotted with their images and their stories. A new study offers some surprising insights, finding that the princesses did make a difference in the behavior of girls — and that they influenced boys as well.

Researchers looked at the rates of engagement with Disney princess media in 198 5- and 6-year-olds, and found that for both boys and girls, higher princess involvement (through toys, products and media consumption) over the course of a year was associated with higher levels of female gender-stereotypical behavior at the end of the study — even after the researchers controlled for other variables.

“It’s not just that girly-girls like princesses,” said Sarah Coyne, a professor of family life at Brigham Young University and lead author of the study, which was published in the journal Child Development. “We were able to completely take that out of the equation, and look at whether there is really long-term growth” in female stereotypical behaviors in children with high levels of princess engagement.

“We found that there was,” she said, and that the media was really “driving” that association “as opposed to the other way around.” That growth in female stereotypical behaviors (like quiet play, pretend cooking and cleaning, and avoiding risks, getting dirty or trying new things), was also observed, to a lesser but still significant degree, in boys with higher Disney princess engagement.

How concerned parents will be about that connection depends on how we perceive those behaviors — and possibly on which gender child we’re thinking about. When it comes to girls, the link between princess involvement and stereotypically female behavior is certainly no surprise, said Rebecca Hains, media studies professor at Salem State University and author of “The Princess Problem.” “It supports what cultural studies critics have been saying for years.” Fear of how the princess narrative influences girls in a culture that often puts more emphasis on how a girl looks and behaves than on how she acts and thinks is nothing new, and Dr. Hains is pleased to see quantitative research backing up the qualitative argument that Disney, as a primary purveyor of all things princess, is contributing to that influence.

But when it comes to boys, Dr. Coyne and her fellow researchers described the increase in stereotypically female behavior as meaning something very different. In girls, they saw an increase in those behaviors as “potentially problematic,” while in boys, the increase in androgyny that the stereotypically female behaviors reflected could, they wrote, have “benefits for development throughout the life span.” That preference for shifting girls away from more traditionally female behaviors while encouraging them in boys is reflected in some popular culture as well, such as commercials for GoldieBlox toys in which girls destroy princess toys and new products designed to encourage doll play among boys.

Why is what’s good for boys bad for girls in this case? It’s all about the starting point, Dr. Hains said. “If girls are already tending in this direction, then increasingly exaggerating the feminine is becoming extreme. For boys, who are already immersed in a hyper-masculine culture, becoming more feminine is becoming more well-rounded.”

As appealing as that desire for the well-rounded boy may sound, Catherine Connors, founder of Demeter Media and the former head of content at Disney Interactive for Women and Family, suggests that the reality is more complicated. “We really get our hackles up at the idea of femininity being encouraged in girls,” she said, and that reaction itself is, she argued, “a manifestation of institutional and cultural sexism.” A former academic, she said her daughter pushed her to rethink her own fears about princesses.

“She asked for a Disney princess snowsuit,” Ms. Connors said. “It was pink, it was sparkly, it was like the platonic ideal of princess merchandise.” (This was before her employment with Disney.) “We’d just bought Spiderman snow boots, which I was happy about, but when I balked at the snowsuit, she just looked at me, and she said ‘Mommy, why don’t you think this is cool?’”

Put on the spot, Ms. Connors bought the snowsuit — and started to rethink the princesses. We’re so worried about the passive, waiting-for-rescue narrative, she said, that we don’t see the positive in even the older stories. “Snow White and Cinderella are active,” she said. “They’re just not necessarily active in masculine ways. We see Cinderella being kind as somehow less noble than going out after a dragon.” Snow White, she said, is “about creating your own community, imagining a life for yourself beyond your situation.”

“There are absolutely things about the princesses that should be looked at with a careful and critical eye,” she said, noting the tendency of the products to depict the active princesses of the movies in pretty but passive (and often sexualized) poses. “We also need to look at the rich legacy of these stories.”

That’s where parents come in. “Our goal is not to kill princess culture,” Dr. Coyne said. “It’s a magical part of childhood that I enjoyed with my own daughter. But we can talk about the characteristics of the princesses — the great things they do, as opposed to what they look like, or what girls look like when they dress up like them.”

Dr. Hains agreed. “Call out the good things,” she said. “She’s pretty and she’s so smart. Belle always has a book in her hands. Anna is really a problem solver. Identify the things that are important to your family.” Focus on the princesses’ qualities that support your values. For parents who want to encourage children to think beyond the Cinderella story, Mulan and Merida (of “Brave”) offer alternative models. Both defy expected gender roles, speak their minds and challenge the traditional expectations for princesses and the princes they supposedly seek. Anna and Elsa of “Frozen” do the same.

Still, there’s no need to go overboard in our explanations, Ms. Connors said. “We wring our hands about girls being snookered by the princess narrative, but we don’t worry about boys being confused about their future as superheroes.”


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Folic Acid During Pregnancy May Lower Risk of Childhood Obesity

Pregnant women should take folic acid, a B vitamin, during pregnancy to prevent neural tube defects in their babies. Now a new study, in JAMA Pediatrics, has found that sufficient folic acid during pregnancy may reduce the risk for obesity in children.

Researchers studied 1,517 mother-child pairs, measuring the mothers’ folic acid blood levels at delivery and following the children through average age 6. After controlling for other variables in both mother and child, they found that compared with those mothers who had folic acid levels in the highest three-quarters, those with levels in the lowest one-quarter had a 45 percent higher risk for obesity in their children.

Folic acid may be especially beneficial for obese mothers. Among obese mothers with the lowest folic acid levels, the risk of obesity in their children more than tripled. But in children of obese mothers, the risk for obesity was 43 percent lower if their mothers were in the top three-quarters for folic acid levels than if they were in the bottom one-quarter.

Experts advise that all pregnant women take a 400-microgram supplement of folic acid daily. But the senior author, Dr. Xiaobin Wang, a pediatrician at Johns Hopkins, said that there is no perfect correlation between the supplement dose taken and blood levels. So “for an overweight mother, it’s probably worth the trouble to do a blood test,” she said. “It’s not an expensive test, and it’s important information. We try to make an individualized decision, and this is a more precise way to do it.”

Your Face Is Beautiful — Do You Want It to Change?

Juliette Borda

One of my daughters was born with a cleft lip. The repair, done when she was an infant, left its mark: Her face isn’t significantly different from the faces around her, but it is different. She knows it, but at 10, she cares a lot more about whether she can outpitch her younger brother than about how she looks in her baseball cap.

But now she needs orthodontic surgery, and there may be a benefit to doing cosmetic facial surgery at the same time. That means tackling a difficult subject — her looks.

How do you ask a child if she would like to change her appearance, without suggesting that something about her needs to change?

I would like to think that I’m raising a child who has absorbed all my lessons about how little our outer appearance matters compared to who we really are, but in reality, I’m raising a girl who has not yet reached her teens, in a world where magazines tell 9-year-olds what bathing suits are best for their body types. Research suggests that girls’ self-esteem plummets at around age 12 and doesn’t start heading upward again until they enter their 20s. In other words, a few short years from now, she’s likely to care about her appearance a whole lot more than she does now. But other research (and common sense) also tells us that how much emphasis our mothers put on our appearance, whether it’s our weight or our faces or anything else, affects how we feel about ourselves.

Our particular challenge might be a little unusual, but the conversation isn’t. Any parent who has talked to a child about doing something to alter the self he or she presents to the world has tried to walk that fine line between proposing a change (braces, acne medication, a healthier diet, straightened hair) and seeming to demand it — and any adult who still hears a parent’s voice judging him or her not thin enough, pretty enough, good enough knows how easy it is to get this one wrong.

“Girls tell themselves these stories about their appearance,” said Catherine Steiner-Adair, a clinical psychologist, the creator of “Full of Ourselves: A Wellness Program to Advance Girl Power, Health, and Leadership,” a program for middle-school girls and the author of “The Big Disconnect: Protecting Childhood and Family Relationships in the Digital Age.” Parents’ words and actions become a part of those stories.

“My mother wasn’t happy with her nose, so I would hear about my nose constantly,” said Jen Lancaster, a novelist and author of the memoirs “Such a Pretty Fat” and “Bitter Is the New Black.” “To this day, I can’t look in the mirror without trying to figure out, ‘Do I need to contour my nose differently today? How does my nose look today?’ This is not a conversation I should ever have with myself, because my nose is fine.”

Too often, Ms. Adair sees parents drawing conclusions from their own experience. A parent who struggled with weight worries that the weight gain many children experience as preteens may become the precursor to a life of teasing and dieting rather than just puberty.

“I tell parents, ‘it sounds like this might be more your issue than hers,’” Ms. Adair said.

The same can happen for parents who want to turn glasses into contacts, straighten or highlight a young teenager’s hair, get braces over with early or worry about girls and boys who want to wear hairstyles or clothing in a way that contradicts our vision of their gender identity. We hear the mocking voices of our own childhood.

Nancy Redd, a former Miss Virginia and the author of “Body Drama: Real Girls, Real Bodies, Real Issues, Real Answers,” says that even when a procedure seems most easily justified, if it’s purely cosmetic, parents like me should think hard before we suggest it.

“We are so arbitrary about what is attractive and what is a disfigurement,” Ms. Redd said. “Mole above the lip? Awesome. On the chin or nose or eyelid? Gross. Wide space between your two front teeth on a low-income woman in rural America? Gross. On a European supermodel? Fabulous.”

Perception, she points out, is everything.

My daughter’s nose, and her scar, and her whole face, are fine, awesome, fabulous. Some experts say it’s better not to talk about weight or appearance at all. I wish it were that simple. I’d love to take the easy way out while getting to declare it the high road. But my daughter may want to look different, and don’t think she’ll thank me for my reticence if it means a second operation when one might have been enough.

When appearance and health overlap, parents who want to talk about a child’s looks just need to be very matter-of-fact, advises Ms. Adair.

“She may not be talking about it because she’s not worried about it, or she may not want you to worry about it,” she said. She suggested that to start the conversation with my own daughter, I could remind her of times when she’s asked about her scar. Ask her if she still thinks about it, and tell her that during her surgery, “the doctors can change that if you want,” she suggested.

Parents can be similarly direct but neutral about other issues, like acne. Saying, “I see you’re getting some pimples” is a better way to preface a visit to the dermatologist than saying, “your skin looks terrible.”

When I suggested to my daughter that orthodontic surgery might give her the opportunity to make other changes, she was interested. And she had thought about her appearance, but not in the way I’d expected. After gently broaching the topic of her childhood surgery, I asked her if she wanted to change the asymmetry of her lips. She shook her head.

Instead, she asked about the symmetry of her nose, which is affected by the pull of the scar. I had never thought about that. I still suspect her upper lip will be on her list when she’s older, but knowing it was her nose she wanted to talk about guided me in asking doctors about timing and combining surgeries.

But even though she wanted answers, the consultation took us both aback. Hearing her face so bluntly discussed was upsetting for my daughter and we interrupted the doctors repeatedly, and finally steered them away from the topic. (We revisited it later, with her out of earshot.) In hindsight we should have talked to the doctor privately first. As Ms. Adair reminded me, it’s fine for parents to tell doctors: “Please do not use language that will echo in her head for years.”

In the end, my daughter’s doctors didn’t want to do anything more than remove a tooth and look around. As for her nose, they said that reconstructions done too early, while a child’s face is still growing, may have to be redone later. She didn’t seem disappointed.

For now, we’ve decided to wait and see if any additional operations are essential before we broach the topic of cosmetic surgery again. We will make health decisions for her, but we will let her decide whether she wants to undergo an optional cosmetic procedure.

And we won’t dwell on it. I don’t want my daughter’s face to look any different, and I never will. But if she does, I want what she wants — and then, I want to go back to talking about baseball.

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Lawsuits Over Baby Powder Raise Questions About Cancer Risk

Tony Cenicola/The New York Times

Deane Berg thought she was going to die, and she wanted to know why. She was 49, way too young, she thought, to have advanced cancer in her ovaries.

As she scrolled through websites that listed possible causes of ovarian cancer, one jumped out at her: talcum powder. She did not have risk factors like infertility or endometriosis, but she had dusted baby powder between her legs every day for 30 years.

“I went into the bathroom, I grabbed my Johnson’s Baby Powder and threw it in the wastebasket,” recalled Ms. Berg, now 59, a physician assistant in Sioux Falls, S.D. “I said, ‘What else could it be?’”

Ms. Berg was the first of thousands of women with ovarian cancer to file a lawsuit against the consumer products giant Johnson & Johnson, claiming that Baby Powder caused their disease and pointing to a long trail of studies linking talc to the cancer. The research dates to 1971, when scientists in Wales discovered particles of talc embedded in ovarian and cervical tumors.

Deane Berg with her husband, Jim. She blamed Johnson’s Baby Powder for her ovarian cancer.

Deane Berg with her husband, Jim. She blamed Johnson’s Baby Powder for her ovarian cancer. David Eggen for The New York Times

Since then, numerous studies have linked genital talc use to ovarian cancer, including a report earlier this month that among African-American women, genital use of powder is linked with a 44 percent increased risk for invasive epithelial ovarian cancer.

Johnson & Johnson says its trademark Baby Powder is safe, and it plans to appeal two multimillion dollar jury awards, including $55 million in damages awarded to a cancer survivor earlier this month and a $72 million award in February.

The International Agency for Research on Cancer in 2006 classified talcum powder as a possible human carcinogen if used in the female genital area. But the agency, part of the World Health Organization, has also said pickled vegetables and coffee are possible carcinogens and that hot dogs cause cancer.

Johnson & Johnson says research implicating talcum powder is flawed and points to studies that absolve talc of any cancer risk.

“We have children ourselves,” said Tara Glasgow, the research and development lead for the company’s baby products franchise worldwide. “We would never sell a product we didn’t believe was safe.”

So did the juries get it right or wrong? Is it plausible that Johnson’s Baby Powder — that clean-smelling soft stuff that’s a medicine cabinet staple, packaged in milky-white containers and supposedly mild enough for babies’ bottom — can cause cancer?

It’s not an easy question to answer.

“There is no way we’re ever going to know for certain that any exposure is necessarily causal to a disease,” said Dr. Shelley Tworoger, an associate professor of medicine and epidemiology at Brigham and Women’s Hospital and Harvard. “We might be 99 percent sure,” in some cases, she said, “but there’s usually no way to guarantee that what you see is actually the truth.”

Cancer is hard to study because it develops over a long period of time and is influenced by many factors, including genes, behaviors and environmental exposures. The best we can do, Dr. Tworoger said, “is look at the preponderance of the evidence.”

Talc is a naturally occurring clay mineral composed of magnesium and silicon. Known for its softness, it is used in cosmetic products like blush because it absorbs moisture and prevents caking. It is also an additive in tablets, chewing gum and some rice. It’s often mined in proximity to asbestos, a known carcinogen, and manufacturers have to take steps to avoid contamination. Many women use the powder on their inner thighs to prevent chafing, while others sprinkle it on their perineum, sanitary pads or underwear to stay “fresh” and dry. A 1980s ad campaign for a once-popular powder promised with a catchy jingle that “a sprinkle a day helps keep odor away.”

There has never been an experiment to see what happens when you deliberately expose women to talcum powder — for practical and ethical reasons, there never will be — so scientists must rely on observational studies that can link an exposure to a disease but cannot determine a cause-and-effect relationship.

In 1982, a Harvard professor, Dr. Daniel W. Cramer, and his colleagues compared 215 women with ovarian cancer and 215 healthy women who served as a control group. Compared with nonusers, women who used talcum powder were at nearly twice the risk for having ovarian cancer, and those who used it regularly on their genitals and sanitary pads were at more than three times the relative risk.

At least 10 subsequent studies echoed the results, with varying degrees of increased risk. But a small number of studies did not find a heightened risk for talc users.

When researchers pooled the results of similar studies involving nearly 20,000 women, they found powder use was associated with a 24 percent increased risk for ovarian cancer, an uncommon disease but one that is often fatal. If the finding is true, it means that for every five or six talcum powder users who develop ovarian cancer, one may be a result of talcum powder use, Dr. Steven A. Narod, an expert in cancer genetics from Toronto, said.

But critics say such studies can get it wrong, because they quiz women about their risk factors after a cancer diagnosis, and people, by nature, have selective memories.

“A patient is looking for reasons, and wondering, Why did this happen to me?” said Dr. Larry Copeland, a gynecologic oncologist from Ohio State University Wexner Medical Center and paid expert for Johnson & Johnson. If a researcher asks a patient about talc use, he said, “The answer is going to be ‘Aha, yeah — maybe that was it.’”

Dr. Copeland points to a large government-funded study, the Women’s Health Initiative. Researchers asked 61,576 women at the beginning of the study whether they had ever used perineal powder (although they did not specify talcum powder) and tracked their health over time. After 12 years, the study investigators found no relationship between powder use and cancer.

But that paper has critics, too. Dr. Narod said that the Women’s Health Initiative cohort was not large enough and did not track women long enough to find differences in ovarian cancer. The findings, he said, do not invalidate the earlier observational research that showed a link between talc and cancer.

Why talc use might lead to cancer is not clear. Studies have shown that talc crystals can move up the urinary tract into the peritoneal cavity, where the ovaries are. Indeed, a pathology report on Ms. Berg’s tumor found talc particles embedded in the tissue.

There is also a plausible mechanism, Dr. Tworoger said, because talc particles can set off inflammation, and inflammation is believed to play an important role in the development of ovarian cancer

Since the research began showing a link between talc and cancer in the 1990s, federal officials have not acted to remove the powders or add warning labels. The nonprofit Cancer Prevention Coalition petitioned the Food and Drug Administration in 1994 and again in 2008 for talc warning labels. In a 2014 denial letter, the agency said there was “no conclusive evidence” to establish causality, though it is plausible that talc “may elicit a foreign-body-type reaction and inflammatory response that, in some exposed women, may progress to epithelial cancers.”

Nevertheless, Johnson & Johnson made plans to “grow the franchise” by targeting African-American and Hispanic customers, according to internal company documents obtained by the plaintiff’s lawyer, Allen Smith. “Negative publicity from the health community on talc (inhalation, dust, negative doctor endorsement, cancer linkage) continues,” a 1992 memo said.

Although Johnson & Johnson’s talc supplier added warning labels in 2006, J&J did not add similar warnings to its products, according to litigation documents. Baby powder does carry a warning to keep it out of the reach of children and many pediatricians discourage its use on babies, who can become ill or die after breathing in the particles. Inhalation studies in female rats demonstrated carcinogenicity, according to the National Toxicology Program. Condom and surgical glove makers have stopped dusting their products with talc.

“Talcum powder is an interesting case, because it’s not something that’s necessary,” said Dr. Anne McTiernan, an epidemiologist with the Fred Hutchinson Cancer Research Center in Seattle. “If there’s any doubt, why should anyone use it?”

As for Ms. Berg — the Sioux Falls woman with advanced ovarian cancer — she won her lawsuit against Johnson & Johnson, but the jury did not award damages. She hopes other talc lawsuits will raise awareness.

“I knew nothing about this before,” she said. “I figured baby powder is for babies, it must be safe.”

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Who You Calling Cheerleader?

One recent Saturday on Staten Island, Brooke Winkler surveyed the pack of teenage girls before her with an expression of barely suppressed fury. Just 20 minutes before the start of its game against Morrisania Educational Campus, from the Bronx, the Susan E. Wagner High School stunt team was fumbling its way through practice. The girls’ landings teetered, their timing lagged and one flier couldn’t seem to maintain her balance. And then there was the matter of congeniality.

“I need you all to smile!” barked Ms. Winkler, 27, a team coach and a math teacher at Wagner. “You look like you want to die out there!”

The girls had every reason to smile. The Wagner Falcons of Staten Island are the reigning city champions of stunt, an increasingly popular variant of cheerleading that focuses on its technical and athletic components. Introduced by the Public Schools Athletic League in 2014, stunt is less rah-rah and more basket tosses.

With a 9-1 record this season, the Falcons are tied for second place heading into the playoffs in early June, where seven other teams will compete for the title. Yet even as the Falcons perfect their form with daily two-hour practices and a pair of games each weekend, their most trying contest revolves around legitimacy.

“When we walk through the hallways, people always tease us that stunt isn’t a real sport,” said Crystal Knapp, 16, a sophomore on the team. “But look at us — we’re athletes. We work hard.”

High school wiseguys are hardly their only detractors. In spring 2014, the N.C.A.A. Committee on Women’s Athletics denied stunt a bid for consideration as an “emerging sport.” Around the same time, competitive cheer, not to be confused with stunt, was deemed an “official high school sport” by the State Board of Regents.

Although stunt has yet to receive the same status, a committee met last month to evaluate its potential for the 2017-18 season, said Todd Nelson, assistant director of the New York State Public High School Athletic Association. And when the stunt program began in New York City two years ago, it gained more traction.

The program has grown to approximately 470 participants playing on 33 teams, from 120 participants in 2014, said Donald Douglas, the Public Schools Athletic League’s executive director.

Stunt competitions unfold with no less seriousness than high school basketball games. Teams perform identical predetermined routines, “so you can see who’s more perfect,” Ms. Winkler said. The arrangement is meant to enable more objective scoring, but it carries the daunting consequence of exposing any minute flaw.

Wagner was forced to confront a blemish of its own in the opening routine of its game against Morrisania, when one girl stumbled out of the wobbling arms of a teammate. It proved to be Wagner’s only blunder. For the rest of the game, their tosses were precise, their tumbling synchronized and their pyramids as exquisitely constructed as any in the sands of Giza. Even as their eyes betrayed their nerves, the girls kept grins plastered across their faces.

The playlist for the contest was a collection of mostly retro techno music selected for its adherence to the sport’s eight-count rhythm and, it would seem, the ability to induce mass frenzy. At one point, a remix of “Rock and Roll All Nite” transitioned into a remix of “Rock You Like a Hurricane,” which transitioned into a remix of “You Shook Me All Night Long.” A more contemporary song that brusquely commands listeners to “Shut Up and Dance” played no fewer than two dozen times.

“I’ve learned to block out the music,” said Martyna Kulikowski, the team’s captain, “but that doesn’t mean I like it.”

With women’s sports on the rise, cheerleading has grown crowded with a variety of iterations all vying for accreditation, among them game day, spirit and stunt. Advocates hope Title IX privileges are in the future. Though the athletic league technically considers stunt a coed sport, only a few teams include boys. The Wagner team is entirely female.

“In cheer, you’re rooting for someone else, usually boys,” Ms. Kulikowski said. “In stunt, everyone else cheers for us.”

Sprawled across the stands between games, the Falcons allowed themselves a few moments to unwind, snacking on doughnuts and chatting. “Being a teenage girl is stressful, and stunt is a sort of escape for a lot of them,” Ms. Winkler said.

Wagner’s second competition of the day proceeded smoothly, as the Falcons defeated Stuyvesant High School, from Manhattan, without losing a single routine. Still, some of the team’s most ardent supporters struggled to watch the action.

“This is the hardest part of my week,” said Natasha Dunn, whose daughter Kayla is a junior on the Falcons.

Even as she kept her iPhone camera steadily trained on her daughter, Ms. Dunn winced at the sight of Kayla being tossed in the air like a mound of pizza dough. Her concerns were understandable. Nearly two-thirds of all catastrophic injuries in female youth sports occur in cheerleading, according to the National Center for Catastrophic Sport Injury Research at the University of North Carolina at Chapel Hill.

Wagner has avoided any major disasters, but the team has not been immune to stunt’s dangers. Last season, one girl’s teeth went through her upper lip after she was elbowed in the face. Another girl broke her pinkie finger. Both were back at practice the next day.

“It’s not just bows and pompoms, these girls are tough,” Ms. Winkler said. “Stunt breaks so many gender stereotypes, and I love that.”

EMAIL: fitcity@nytimes.com

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American Girl Has a Hit With Diabetes Doll Kit

Anja Busse, 13, plays with her American Girl doll, Alice, and her diabetes care kit at her home in Antigo, Wis.

Anja Busse, 13, plays with her American Girl doll, Alice, and her diabetes care kit at her home in Antigo, Wis. Corey J. Schjoth for The New York Times

Children with Type 1 diabetes can’t make their own insulin, so they have to count carbs, prick their fingers to check their blood sugar and get regular insulin infusions.

Now they can also give that care to their dolls.

American Girl, the doll company, has introduced a diabetes care kit for dolls, and it has been available only intermittently because it’s so popular.

The kit, which sells for $24, has 10 doll-size make-believe items, including a blood sugar monitor, a lancing device, an insulin pump that can be clipped to a doll’s waistband with an adhesive to attach the infusion set, as well as an insulin injection pen needle (for dolls not using the pump). There are also a vial of pretend glucose tablets, a medical bracelet, an ID card, logbook and stickers, and everything fits in a bright fuchsia carrying case the size of a small change purse.

Anja Busse, a 13-year-old from Antigo, Wis., who has Type 1 diabetes, has wanted a kit like this for her doll since she learned she had diabetes just over two years ago. She started an online petition urging American Girl to make diabetes accessories for the dolls, rallying the Type 1 diabetes community and garnering 7,000 signatures.

Anja learned that she had the disease in October, 2013, when she was 11. That Christmas, she got her first American Girl doll – which had hazel eyes, blond hair and freckles, just like her — but was disappointed when she scoured the catalog and couldn’t find any diabetes supplies (though she quickly accumulated accessories for girls with disabilities, like a service dog and a wheelchair).

Since then, Anja has become an advocate who educates her peers and adults in her life about Type 1 diabetes. Many people confuse Type 1 diabetes, which develops when the immune system destroys the cells that make insulin, and Type 2 diabetes, which develops when the body can’t use insulin properly. While Type 1 is genetic and cannot be prevented, being overweight and inactive increases the risk of Type 2 diabetes, which is a far more common disease.

“There are a lot of things people just don’t understand,” Anja said. “They would try to give me advice and say I should be on a diet, or that they had a cure for this. One person yelled at me not to eat a cupcake. They confuse it with Type 2 diabetes, and all kinds of rumors that aren’t even true.”

One of the things she always tells her friends, she said, is “You can’t catch it.”

She recently took the doll diabetes kit to help explain Type 1 diabetes to a group of kindergartners.

Buyers have posted rave reviews of the kit on American Girl’s website.

“I ordered this the day it came out,” a teenager wrote. “When my dad showed me, I almost cried. I was diagnosed with Type 1 diabetes when I was seven years old and I bought my first AG doll when I was eight.” She said she bought the diabetes kit the day before her 14th birthday.

A mother wrote, “Finally there’s something for girls with Type 1 diabetes to play with that makes them feel like they fit it, and can get some awareness out there.”

“It makes dealing with this disease a little more tolerable,” wrote another mother.

Type 1 diabetes, which is usually diagnosed in children and adolescents, is on the rise for unknown reasons. The symptoms include intense thirst and dehydration, frequent urination, extreme hunger, fatigue and weakness, abdominal pain, irritability and rapid mood changes, nausea or vomiting, wounds that don’t heal and blurred vision. Signs include low body temperature, rapid heart rate, reduced blood pressure and weight loss.

“American Girl has a long-standing history of creating dolls that speak to diversity and inclusion, so it’s not really new for us to come out with dolls that are a reflection of girls today,” said Stephanie Spanos, a company spokeswoman.

The company has a historical line that includes Hispanic, African-American, Jewish and Native American characters, as well as the Truly Me line of dolls that can be ordered to have the same skin tone, eye and hair color as the little girls who own them.

Girls can order outfits, miniature musical instruments, art supplies and athletic gear for their dolls, and small pretend wheelchairs, eye glasses, hearing aids and service dogs are also available. Customers can custom order a doll without hair for a girl who has alopecia or is going through chemotherapy, and arm crutches were introduced in January.

The idea for a diabetes care kit “came to fruition just like any other product – our design team is constantly bringing forth new ideas for accessories and clothes,” Ms. Spanos said.

Matt Wahmhoff, the designer who developed the kit for American Girl, said he was thrilled to be part of the effort because he has Type 1 diabetes himself. “I was diagnosed at age 11, and it really made me feel different,” Mr. Wahmhoff, who is now 42, said. “My friends were clueless, and I didn’t have a way to share it so I kept it inside me.”

Now little girls will be able to incorporate diabetes in their play, “not only when they play with their dolls, but when they interact and play with their friends, and raise awareness,” he said.

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Flu Shots Protect Babies, Too

Here’s one more reason pregnant women should get a flu shot: It not only protects mothers, but a large study suggests it prevents flu in the infant, too.

Giving babies under 6 months old a flu vaccination does not work. Their immune systems are too immature to mount an effective response. But infants can get the flu, and it can have serious, even deadly, consequences.

Researchers used data on live births among women in a large health maintenance organization, including 23,847 babies born to mothers who had been vaccinated against the flu and 225,540 born to mothers who were not vaccinated. The study, published in Pediatrics, was carried out during the H1N1 flu pandemic of 2009-10.

Babies of unvaccinated women were 70 percent more likely to have a laboratory-confirmed case of flu, and 81 percent more likely to be hospitalized for flu before they were 6 months old.

The lead author of the study, Dr. Julie H. Shakib, an assistant professor of pediatrics at the University of Utah, said that after the 2009-10 pandemic, rates of vaccination of pregnant women went up sharply. In the 2013-14 season, more than 50 percent of pregnant women were vaccinated.

“We were encouraged to see the increase after the pandemic,” she said. “That’s when the public became aware of how much of a risk there was, and when obstetrics practices started delivering the vaccine as a routine part of care.”

Bodily Changes Are Driving Girls Out of Sports

Harriet Lee-Merrion

Spring, finally!

So why aren’t more teenage girls out on the playing fields?

Research shows that girls tend to start dropping out of sports and skipping gym classes around the onset of puberty, a sharp decline not mirrored by adolescent boys.

A recent study in The Journal of Adolescent Health found a surprisingly common reason: developing breasts, and girls’ attitudes about them.

In a survey of 2,089 English schoolgirls ages 11 to 18, nearly three-quarters listed at least one breast-related concern regarding exercise and sports. They thought their breasts were too big or too small, too bouncy or bound too tightly in an ill-fitting bra. Beginning with feeling mortified about undressing in the locker room, they were also self-consciously reluctant to exercise and move with abandon.

Experts on adolescent health praised the study for identifying and quantifying an intuitive thought.

“We make assumptions about what we think we know, so it’s important to be able to say that as cup size increases, physical activity decreases for a lot of girls,” Dr. Sharonda Alston Taylor, an assistant professor of pediatrics at Baylor College of Medicine in Texas, who focuses on adolescent obesity.

The challenge is what to do about it.

After reading the study, some pediatricians and adolescent health specialists said they needed to do a better job informing girls about breast health and development. Almost 90 percent of the girls in the study said they wanted to know more about breasts in general, and nearly half wanted to know about sports bras and breasts specifically with respect to physical activity.

Joanna Scurr, the lead author of the study and a professor of biomechanics at the University of Portsmouth in England, said the breast itself had little internal support, so when a girl’s body moved, the breast moved independently, and the movement increased with breast size. In up to 72 percent of exercising women, she said, that movement was a cause of breast pain or discomfort.

Yet while sports and physical education programs frequently recommend protective gear for boys, like cups, athletic supporters and compression shorts, comparable lists for young women rarely include a mandatory or even recommended sports bra.

Only 10 percent of the girls surveyed said they always wore a sports bra during sports and exercise. More than half had never worn one.

Dr. Taylor said that lack of education about bra fitting and sizing was commonplace in her practice.

“The mom will say, ‘I don’t know what size she is,’ and the patient will say, ‘I just grab my sister’s or my mother’s bras to wear.’”

Using data from this study and others, the researchers from sports and exercise health departments at three British universities are trying to design school-based educational programs.

When researchers asked the girls how they would prefer to receive breast information — via a website, an app, a leaflet or a private session with a nurse — the overwhelming majority replied that they wanted a girls-only session with a female teacher.

At what age? “Most of them said 11,” Dr. Scurr said.

Andria Castillo, now 17 and a junior at Mather High School in Chicago, says she remembers that when she was around that age, she was painfully self-conscious about her breast size; she thought she was developing more slowly than everyone else.

“I felt boys and girls were making fun of me,” she said. “Even though no one called me out, I felt they were, behind my back. I was taking taekwondo, and I would look in the big mirror and try to find ways to cover myself up and hide. I asked my dad if I could stop going.”

She had a friend who had been active in sports. But in the sixth grade, the girl’s breasts developed rapidly. “She eventually stopped going to gym altogether,” Ms. Castillo said. “Instead, she just went to a classroom and did her homework.”

In time, Ms. Castillo turned her attitude around; she is now on her school’s varsity water polo and swim teams. She credits not only her mother, but also a Chicago-based project, Girls in the Game, which has body-positive, confidence-building programs, including single-sex athletics.

Some experts in female adolescent obesity and fitness suggested that young girls would be more comfortable in single-sex gym classes. But others said that option had its disadvantages, too.

Kimberly Burdette, a doctoral candidate in psychology at Loyola University Chicago who looks at the psychological factors that promote well-being and healthy weight in girls, says such separation might be helpful at a time when adolescent girls had a heightened awareness that others were looking at their bodies.

“It’s hard to be in the zone, focusing on athletic movement, on what your body can do, if you’re thinking about what others think your body looks like,” she said. “I like programming that is for girls only, where a girl can try a sport, regardless of her ability, without the male gaze.”

But Elizabeth A. Daniels, an assistant professor of developmental psychology at the University of Colorado Colorado Springs, disagreed. “I’m not sure the concern or embarrassment is always just about boys,” she said, noting that girls can make derisive comments about one another. “So do we change the structure of the gym class or address respectful behavior?”

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Treating Pregnant Women for Depression May Benefit Baby, Too

Treating pregnant women for depression may benefit not just themselves but their babies as well.

A study, in the May issue of Obstetrics & Gynecology, included 7,267 pregnant women, of whom 831 had symptoms of depression. After controlling for maternal age, race, income, body mass index and other health and behavioral characteristics, the researchers found that depressive symptoms were associated with a 27 percent increased relative risk of preterm birth (less than 37 weeks of gestation), an 82 percent increased risk of very preterm birth (less than 32 weeks of gestation), and a 28 percent increased risk of having a baby small for gestational age.

They also found that among those who were treated with antidepressants for depression — about a fifth of those with the diagnosis — there was no association with increased risk for any of these problems. But they acknowledge that this group was quite small, which limits the power to draw conclusions.

Still, the lead author, Dr. Kartik K. Venkatesh, a clinical fellow in obstetrics and gynecology at Harvard, said that it was important to screen mothers for depression, not only for their health but for that of their babies.

“By screening early in pregnancy, you could identify those at higher risk and counsel them about the importance of treatment,” he said. “Treating these women for depression may have real benefits.”

Notifications About Dense Breasts Can Be Hard to Interpret

Dr. Dorothy Lam explains the results of a mammogram to a patient at Swedish Covenant Hospital in Chicago in 2015.

Dr. Dorothy Lam explains the results of a mammogram to a patient at Swedish Covenant Hospital in Chicago in 2015. Taylor Glascock for The New York Times

About 40 percent of women who have mammograms are found to have dense breast tissue, a normal finding that can make it harder to detect cancer. But many of these women receive letters in the mail about the finding that can be hard to decipher, a new study found.

“Twenty percent of the population only reads at an eighth-grade level, and many more don’t read at a much higher level than that,” said Nancy R. Kressin, one of the study’s authors who is a professor at Boston University School of Medicine and a senior researcher at the Veterans Affairs Boston Healthcare System.

“For many women, these notifications are not going to be easy to read” and might even be alarming, she said. “We’ve talked to some women who received these letters, and their reaction was ‘Oh my God, I have cancer.’ ”

Dense breast tissue means that a woman’s breasts have more connective and fibrous tissue than usual. Dense breasts both increase the risk of breast cancer and make it less likely that tumors will be seen on a mammogram, but having dense breasts does not mean a woman has cancer.

The study, published as a letter in JAMA, analyzed the notification letters sent out in 23 states and found that many use such complex language that patients need a college degree to understand them. The letters sent out in New Jersey and Connecticut were written at a postgraduate degree level, the report found. Yet only 12 percent of American adults have proficient health literacy, according to the National Assessment of Adult Literacy.

For years women were not routinely informed of the finding. Now, 26 states have laws on the books that require mammography testing facilities to tell women who have the breast cancer imaging scans if they have dense breast tissue as part of their results, according to Nancy Cappello, who founded Are You Dense?, a nonprofit organization that educates the public about the risks of dense breast tissue.

She acknowledged that the notification letters, which are crafted during the legislative process and are different in every state, may be complex but said they are meant to trigger a discussion between the patient and her doctor.

The notifications were “never intended to replace conversations, but to enhance them,” said Dr. Cappello, who was given a diagnosis of advanced breast cancer in early 2004, weeks after receiving a “normal” result from a mammogram. After her diagnosis, she learned that she had dense breast tissue. But although she had been having mammograms every year for over a decade, she was never informed she had dense breasts and that the scans were less reliable as a result.

She called the study “shortsighted” because it evaluated several sentences of a letter in isolation, “without assessing the readability of the entire report.”

“Why don’t the authors question the readability levels of all medical reporting results that patients receive?” Dr. Cappello asked.

The new analysis in JAMA measured the readability and understandability of notification letters and found that most were written at a level higher than the recommended seventh- or eighth-grade readability level, and many were at a high school or college readability level.

All of the letters informed women that dense breasts can mask cancer on mammography. Most also informed women that dense breasts are associated with an increased cancer risk and mentioned the option of getting screened by another method, suggesting the woman talk to her doctor.

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Thriving at Age 70 and Beyond

Paul Rogers

A recently published book, “70Candles! Women Thriving in Their 8th Decade,” inspired me to take a closer look at how I’m doing as I approach 75 and how I might make the most of the years to come. It would be a good idea for women in my age cohort to do likewise. With a quarter of American women age 65 expected to celebrate their 100th birthday, there could be quite a few years to think about.

It’s not the first time I’ve considered the implications of longevity. When one of my grandsons at age 8 asked, “Grandma, will you still be alive when I get married?” I replied, “I certainly hope so. I want to dance at your wedding.” But I followed up with a suggestion that he marry young!

Still, his innocent query reminded me to continue to pursue a healthy lifestyle of wholesome food, daily exercise and supportive social connections. While there are no guarantees, like many other women now in their 70s, I’ve already outlived both my parents, my mother having died at 49 and my father at 71.

If I have one fear as the years climb, it’s that I won’t be able to fit in all I want to see and do before my time is up, so I always plan activities while I can still do them.

I book cycling and hiking trips to parts of the world I want to visit and schedule visits to distant friends and family to be sure I make them happen. In a most pragmatic moment, I crocheted a gender-neutral blanket for my first great-grandchild, but attached a loving note in case I’m no longer around to give it in person.

Of course, advancing age has taken — and will continue to take — its incremental toll. I often wake up wobbly, my back hates rainy days, and I no longer walk, cycle or swim as fast as I used to. I wear sensible shoes and hold the handrail going up and down stairs.

I know too that, in contrast to the Energizer Bunny life I once led, I now have to husband my resources more carefully. While I’m happy to prepare a dish or two for someone else’s gathering, my energy for and interest in hosting dinner parties have greatly diminished. And though I love to go to the theater, concerts, movies and parties, I also relish spending quiet nights at home with my Havanese, Max, for company.

Jane Giddan and Ellen Cole, the authors of “70Candles!,” do not tout their work as definitive research. Rather, their effort involved scores of posts to an online blog, and eight gatherings in different cities with groups of women in or near their 70s, where participants were encouraged to share their stories and generate research questions that could be explored scientifically in more detail. Such studies are important: As baby boomers age, women in their 70s, already a large group, will represent an increasing proportion of the population, and how to best foster their well-being will be a growing challenge.

What are the most important issues facing these women as they age, and how might society help ease their way into the future? Leading topics the women chose to explore included work and retirement, ageism, coping with functional changes, caretaking, living arrangements, social connections, grandparenting and adjusting to loss and death.

As members of the first generation in which huge numbers of women had careers that defined who they were, deciding when to bow out can be a challenge. Some have no choice, others never want to, and still others like me continue to work part-time. However, sooner or later, most will need to find rewarding activities to fill their now-free time.

The authors reported that “the women seemed to fear retirement before the deed was done, and then to relish their newfound opportunities afterward.” Several warned against rushing into too many volunteer activities, suggesting instead that retirees take time to explore what might be most meaningful and interesting, from taking art classes or music lessons to mentoring students, becoming a docent or starting a new career.

As one woman said, “There are many places where you are needed and can make a difference.” Another said, “It’s more like putting new tires on a car… re-tiring!”

Still, many lamented society’s focus on youthfulness and its failure to value the wisdom and knowledge of elders like themselves. Ageism abounds, they agreed. As one woman wrote, “At my institution, there’s an unstated policy that anyone over 55 won’t get a job. We’re thought to be out of touch with the younger population and assumed to be lacking in the necessary technical skills.” A practicing attorney admitted, “People might not listen to me if they knew I was 71, so I keep it to myself.”

Adjusting to physical changes that accompany advancing years is often tough. Grandchildren, though a great joy to many, can be exhausting, necessitating a restorative nap. Adjustments are needed to reduce the risk of falls and fractures. Better lighting, hearing assists, a reliance on Post-it notes and lists as well as canes and walkers can become essential for safe and effective functioning.

As Ms. Giddan and Ms. Cole wrote, “Our bodies change as we age, even when we eat healthfully, exercise and try to take good care of ourselves. Sight, hearing, bones, joints, balance, mobility, memory, continence, strength and stamina — they will never be what they once were.”

There is also the matter of attending to or accommodating various aches and pains. As one physician reassured a woman of 70, “All my patients your age who are free of pains are dead.” I’m not one to run to the doctor the moment something hurts. Rather, I give it a few weeks — maybe a month — to see if it will go away on its own. Even if fully covered by Medicare, doctor visits cost time and effort, and tests that ensue may have side effects.

Also important as women age are social connections, especially with other women. Whether married, single, widowed or divorced, participants reported that women friends were their greatest source of support and comfort.

Perhaps most important, for men as well as women, is to think positively about aging. A 2002 study by epidemiologists at Yale found that “individuals with more positive self-perceptions of aging, measured up to 23 years earlier, lived 7.5 years longer than those with less positive perceptions.”

This is the first of two columns on adjustments to aging.

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At 100, Still Running for Her Life

100 and She Just Won’t Stop

She is a national champion, a former activist and a centenarian. And she runs.

By NOAH REMNICK and ERICA BERENSTEIN on April 22, 2016. Photo by Elias Jerel Williams for The New York Times.

On a cloudless Sunday afternoon in April, a 100-year-old woman named Ida Keeling laced up her mustard yellow sneakers and took to the track at the Fieldston School in the Bronx. Her arrival was met without fanfare. In fact, no one in the stands seemed to notice her at all.

It is possible the spectators were distracted by the girls’ soccer game taking place on the field. Or perhaps they were simply unaware that Ms. Keeling is a reigning national champion.

Ms. Keeling, 100, holds a record for the 60-meter dash for American women ages 95 to 99.

Ms. Keeling, 100, holds a record for the 60-meter dash for American women ages 95 to 99. Elias Jerel Williams for The New York Times

When she runs, Ms. Keeling occupies a lane all her own. She has held several track-and-field records since she began racing in her late 60s, and she still has the fastest time for American women ages 95 to 99 in the 60-meter dash: 29.86 seconds. In the week to come, she plans to compete in a 100-meter event at the Penn Relays in Philadelphia, where she hopes to establish a new standard for women over 100 years old.

“You see so many older people just sitting around — well, that’s not me,” said Ms. Keeling, who is barely 4-foot-6 and weighs 83 pounds. “Time marches on, but I keep going.”

Ms. Keeling was not always such an accomplished runner. As a child growing up in Harlem, she preferred riding bikes or jumping rope. With Title IX half a century away, there were few opportunities for girls, let alone black girls, to play organized sports. When she did run, it was always to race, never to exercise.

“I was pretty fast as a girl,” she said. “What makes me faster now is that everyone else slowed down.”

When the Depression hit, Ms. Keeling’s athletic inclinations receded into memory, supplanted by a series of jobs washing windows and babysitting for neighbors. Her family, who for years lived in cramped quarters in the back of her father’s grocery, was forced into even more humbling circumstances when the store went out of business and her father began peddling fruits and vegetables from a pushcart for a living.

“I learned to stand on my own two feet during the Depression,” she said. “It taught you to do what you had to do without anyone doing it for you.”

Shelley Keeling, left, and her mother, Ida Keeling, on a balcony in the Riverdale section of the Bronx.

Shelley Keeling, left, and her mother, Ida Keeling, on a balcony in the Riverdale section of the Bronx. Elias Jerel Williams for The New York Times

Ms. Keeling’s resilience only deepened with time. After her husband died of a heart attack at 42, she was left to raise their four children on her own. She moved the family into a one-bedroom apartment in a Harlem housing project and took up work sewing in a factory, all the while contending with the abuses and indignities endured by black women in mid-20th-century America. As the civil rights movement took shape, Ms. Keeling became an active demonstrator, shuttling her children to Malcolm X speeches and boarding a predawn bus for the 1963 March on Washington.

“I always understood from mother that you die on your feet rather than live on your knees,” said her daughter Shelley Keeling.

Over time, that resolve was gravely tested. While serving overseas in the Navy, Ms. Keeling’s older son, Donald, developed a crippling drug addiction that he struggled to shed even after returning home to Harlem. His habit ensnared his younger brother, Charles, who had served in the Army. Ms. Keeling watched in horror as both boys, barrel-chested charmers who friends joked looked like superheroes, withdrew into the world of drugs.

Ms. Keeling stretched her legs in her daughter’s living room in the Bronx last month.

Ms. Keeling stretched her legs in her daughter’s living room in the Bronx last month. Elias Jerel Williams for The New York Times

In 1978, Ms. Keeling received a call from the police informing her that Donald had been hanged. Around two years later, the phone rang again: Charles was dead — beaten in the street with a baseball bat. Both killings were suspected to be drug-related; neither was ever solved.

“I’ve never felt a pain so deep,” Ms. Keeling recalled, her voice lowering to a whisper. “I couldn’t make sense of any of it and things began to fall apart.”

A stretch to improve Ms. Keeling’s blood flow and flexibility.

A stretch to improve Ms. Keeling’s blood flow and flexibility. Elias Jerel Williams for The New York Times

As Ms. Keeling fell into a deep depression, her health began to falter. Her blood pressure shot up, along with her heart rate. The image of her once-vital mother in such despair shook the younger Ms. Keeling. A lifelong track-and-field athlete whose trophies fill an entire room of her apartment, she intervened with the means of healing most familiar to her: running.

“It was trial by fire,” recalled Shelley Keeling, 64, who has coached track and field at Fieldston for 21 years. “Based on where she was emotionally, it just had to be.”

After some coaxing from her daughter, Ms. Keeling, then 67, registered for a five-kilometer race through Brooklyn. It had been decades since she had last gone running. The two women took off together, but the younger Ms. Keeling soon darted to the front of the pack as her mother drifted far behind. After a suspenseful respite, was relieved to see her mother scamper across the finish line, barely out of breath.

“Good Lord, I thought that race was never going to end, but afterwards I felt free,” Ms. Keeling recalled. “I just threw off all of the bad memories, the aggravation, the stress.”

So began the sunset career of Ida Keeling, at a time when most of her peers were settling in for a future of seated yoga or abandoning athletics altogether. In the decades since, she has traveled across the world for competitions. She often races alone, the only contestant in her age group.

“Now I’m just chasing myself — there’s no one else to compete with,” she said. “It’s wonderful, but it feels a little crazy.”

Running gives Ms. Keeling a sense of serenity, she said. Her sinewy arms urge her body forward, each stride stronger than the last as she picks up momentum. Though she has developed arthritis and occasionally relies on a cane while walking, Ms. Keeling betrays none of her ailments as she runs.

To maintain her health, Ms. Keeling adheres to a stringent regimen of diet (“I eat for nutrition, not for taste”) and exercise (“I’ve got to get my hour in every day”). On a recent afternoon, Shelley Keeling led her mother through a routine that included push-ups, wall sits, shoulder presses and sprints back and forth on the balcony of her apartment in the Riverdale section of the Bronx. Ms. Keeling lives alone and says that self-sufficiency is a key to her longevity.

“I don’t beg nobody for nothing,” she said. “I wash, cook, iron, scrub, clean, mop and shop.”

Ms. Keeling exceeded the five push-ups that her daughter had asked of her.

Ms. Keeling exceeded the five push-ups that her daughter had asked of her. Elias Jerel Williams for The New York Times

Ms. Keeling eschews food products with preservatives, favoring fresh grains and produce, along with limited portions of meat. Desserts are rarities, and a tablespoon of cod-liver oil supplements breakfast most mornings. Despite her exceptional discipline, Ms. Keeling allows herself one indulgence. “This is putting gas in the car,” she said before downing a tall shot of Hennessy.

There are days when Ms. Keeling battles a surge of arthritis or a hint of melancholy. “I never want to go backwards,” she said. “I’m a forward type of person.”

As she navigated the track at Fieldston, a nasty cramp shot up her right leg, hobbling her gait. For a moment she seemed to hesitate as she let out a deep sigh and slowed her pace. But then Ms. Keeling dispensed with the pain the only way she knew how. She ran through it.

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Why Do Girls Tend to Have More Anxiety Than Boys?

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The laid-back, underachieving boy; the hyperachieving, anxious girl. Over the three decades since I graduated from medical school, and especially over the past 10 years, this pattern has become increasingly common in my practice.

In one case, which is pretty typical, my patient’s parents are concerned about their son. He’s not working hard at school and his grades are sliding. At 16, he spends most of his free time playing video games like Grand Theft Auto or Call of Duty, or surfing the Web for pictures of girls. He’s happy as a clam.

Both parents are actually quite proud of their 14-year-old daughter, who is a straight-A student, an athlete and has many friends. But when I met with her, she told me that she isn’t sleeping well. She wakes up in the middle of the night, feeling remorseful about having eaten a whole slice of pizza for dinner. She often has shortness of breath. Recently she has begun cutting herself with razor blades, on her upper inner thigh where her parents won’t see. She hasn’t told her parents any of this. On the surface, she is the golden girl. Inside, she is falling apart.

Why is it that girls tend to be more anxious than boys?

It may start with how they feel about how they look. Some research has shown that in adolescence, girls tend to become more dissatisfied with their bodies, whereas boys tend to become more satisfied with their bodies. Another factor has to do with differences in how girls and boys use social media. A girl is much more likely than a boy to post a photo of herself wearing a swimsuit, while the boy is more likely to post a photo where the emphasis is on something he has done rather than on how he looks. If you don’t like Jake’s selfie showing off his big trophy, he may not care. But if you don’t like Sonya’s photo of herself wearing her bikini, she’s more likely to take it personally.

Imagine another girl sitting in her bedroom, alone. She’s scrolling through other girls’ Instagram and Snapchat feeds. She sees Sonya showing off her new bikini; Sonya looks awesome. She sees Madison at a party, having a blast. She sees Vanessa with her adorable new puppy. And she thinks: I’m just sitting here in my bedroom, not doing anything. My life sucks.

Boys are at lower risk for the toxic effects of social media than girls are, for at least three reasons. First, boys are less likely to be heavily invested in what you think of their selfies. “Does this swimsuit make me look fat?” is a question asked by girls more often than by boys. Second, boys tend to overestimate how interesting their own life is. Third, the average boy is likely to spend more time playing video games than Photoshopping his selfie for Instagram. And in video games, unlike social media, everybody truly can be a winner, eventually. If you play Grand Theft Auto or Call of Duty long enough, you will, sooner or later, complete all the missions, if you just keep at it.

Parents can’t easily change any of those factors. You can’t easily get a girl to be less concerned about her looks; or to overestimate how interesting her own life is; or to care more about completing all the missions in Grand Theft Auto than about how many likes she’s getting on Instagram (nor is it clear that this last change, even if accomplished, would be a change for the better). So what can you do, to improve the odds for your daughter?

If your daughter is the girl sitting in her bedroom looking at other girls’ social media, maybe she shouldn’t be in her bedroom at all. In the typical American household today, when kids go home, they go to their bedrooms and aren’t seen again except perhaps for meals. That’s crazy. A family can’t be a family if the kids spend more time alone in their bedrooms than with their family members. Insist that your daughter, or son, do whatever they’re doing online in a public space: in the kitchen or the living room. There should be nothing in the bedroom except a bed: no TV, no PlayStation, no screens. That’s the official recommendation of the American Academy of Pediatrics.

Another suggestion: fight for suppertime. And don’t allow phones at the table. In a 2013 Canadian survey of kids across a range of backgrounds, those who had more meals with parents were much less likely to have been feeling sad, anxious or lonely. They were more likely to help others and more likely to report being satisfied with their own lives. But be mindful of what you say at the table. Discussions of poor grades or disappointing test scores are out of bounds. The Palestinian-Israeli conflict? Of course. The origin of the universe and the meaning of life? Certainly. But the personal shortcomings of your child are, as a rule, not appropriate suppertime conversation in a loving family.

A third suggestion: No headsets and no earbuds in the car. When your child is in the car with you, you should be listening to her and she should be listening to you – not to Justin Bieber or Miley Cyrus or Akon or Eminem. Teach the art of face-to-face conversation. Or play a word game. Or have the whole family sing a song. Or make up a limerick, as my family and I did last night. It sounds corny, but it helps.

If your daughter is not sleeping at night, or is cutting herself with razor blades, then limericks at the dinner table are not likely to be a sufficient cure. I do prescribe medication, cautiously and judiciously, for the clinically anxious girl. There is also a role for professional counseling, alongside or sometimes in place of medication. Regardless, medication should never be the most important part of the treatment. The most important part of the treatment is to prioritize the family, to give your child a secure grounding in a loving home.

Leonard Sax is a psychologist and a practicing family physician in West Chester, Pa., and the author, most recently, of “The Collapse of Parenting.”

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Should Moms Manage the Money?

“Daddy has to work! You have to come pick us up!”

When Kimberly Palmer heard those words come out of the mouth of her 5-year-old daughter, she was dumbfounded. Both she and her husband have full-time jobs, so where had the little girl gotten the idea that Daddy’s work mattered more?

Ms. Palmer didn’t know, but she took it as a call to action. Although she’s written about the topic of money management for a living for many years, she wasn’t handling many of the money management tasks in her own household.

So her advice for heterosexual women in two-parent households in her coming book, “Smart Mom, Rich Mom,” is this: Moms should be in charge of the management of household finances. All of them. Always.

Many couples will bristle at the idea that any family task other than breast-feeding should be assigned on the basis of anatomy, even if they are often self-selecting in this manner by choice.

In many households, men tend to manage family investments and taxes, and women, if they get involved in money issues, tend to focus only on everyday expenses and charitable donations.

A 2014 UBS Wealth Management Americas report noted that when it comes to investing, however, it’s men making the decisions alone half the time. Another 37 percent of couples shared the decisions, while just 13 percent of women made them alone. Among younger women, just 15 percent of millennials and 18 percent of Generation Xers were flying solo.

Same-sex couples often have separate accounts and make individual decisions, which is probably a legacy of the fact that it was hard for them to marry and combine accounts until recently.

One reason men may handle investing more often is that they tend to come into a marriage with more assets. A 2014 Wells Fargo study of millennials reported that the males had both a higher median household income ($83,000 vs. $63,000 for women) and higher median assets that were available for investing ($59,000 vs. $31,000).

Or perhaps men simply like handling this task more. Does it really make sense to take it away from them? Ms. Palmer pushes back against concerns over prescribed gender roles in three ways.

First, women tend to be better investors. Studies have shown that men have a bit too much confidence and take a bit too much risk. One seminal piece of research in this area showed how badly men’s investment returns suffered because they traded their stocks too often. A 2015 book called “Women of the Street: Why Female Money Managers Generate Superior Returns (and How You Can Too)” sums up the case for those who want to know more — or slip a treatise under their husband’s pillow.

Second, when mothers are the money leaders in the household, children take notice. For years, surveys of families have found that parents talk to girls less often about money than they talk to boys and that teenage boys end up believing they will earn more. Ms. Palmer clearly didn’t much enjoy finding out that her daughter viewed her as a driver and her dad as an earner. Moms who manage the money serve as role models who can counteract some of these problems.

Finally, many women will have to be in charge of the money sooner or later, so having some experience as the primary household money manager is essential. Women outlive men, and there are about four times as many widows as widowers in the United States, according to Ms. Palmer’s research. All of us who toil in the personal finance salt mines hear stories of widows who had to start reassembling their financial lives from scratch when their husbands died suddenly. When you are sad and older, you do not want to find yourself locked out of the household accounts, literally.

Divorce happens, too, so it’s good for both spouses to know where the money is (and if it’s been moved around recently) in the event of a surprise separation.

While Ms. Palmer wants women to be the financial captains of the family, she is not advocating a dictatorship. A couple’s financial discussions should be collaborative, whether the person executing the decisions is male or female. So you sit down at least once a year and remind yourselves of the answers to the following questions: Where is our money now? How do we get to it? Has our willingness to take risks with our investments changed? What are the most important goals for the next year? And what do we want to change?

Reading “Smart Mom, Rich Mom” made me acutely uncomfortable, precisely because I could not shake the feeling that I was doing it wrong. At the very least, my wife should be making all the moves for 12 months at a time, once every few years.

As for Ms. Palmer, she now has the password to the Excel spreadsheet her husband made that contains all of their financial information. And she’s started bringing her wallet along most everywhere she goes, even if it is a bit bulky.

That way, she hopes, her daughter will understand that her mom is just as invested in the money that gets made and spent in their family as her father is.

Ron Lieber is the Your Money columnist for The New York Times and the author of “The Opposite of Spoiled,” about parenting, money and values.

For Women Who Run, the Bathroom Problem

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On a recent weekend trip to Washington, I was running in Rock Creek Park when the water and coffee I’d had that morning caught up with me. I’d run there only once before so was unsure where relief lay. I’m also a woman, so I couldn’t just pull over to the nearest bush or tree and relieve myself discreetly, the way guys do, through the benefits of outdoor plumbing.

And then, like a beacon of hope and light, just as the need became painfully pressing, I came across a Porta-Potty. One big problem: It was perched on the side of the road, inches from two lanes of traffic, with a door that opened into those lanes. I waited for a gap in traffic, opened the door, ducked in and did the deed greatly relieved, but through it all hoping that a stiff wind wouldn’t push me over into the road or that I would meet my demise on my way out.

When to go and where to go is a tricky issue for female runners.

On training runs, at least I can plan. I make sure my route intersects with at least one coffee shop, fast-food restaurant or that one Porta-Potty in the park near my house that’s always clean.

But races can be far more unpredictable.

One choice is to throw modesty to the wind and simply bare all. But that involves some deep squatting — not something that’s always easy to do on race-weary legs. The problem is made even worse if, like me, you wear shorts that are tight instead of baggy and must be pulled all the way down to the knees to go.

Another option is to give up many precious seconds, or even minutes, waiting in line for a Porta-Potty that may or may not be where you need it, when you need it, and then going through the motions to get out of your shorts, then back into them.

Or, you can always just let it go and hope that no one notices. One female runner I know, who asked to remain anonymous, couldn’t get through the bathroom line at the start of the 2013 Philadelphia Marathon. So she let loose as the race started, grateful that she was wearing sweat wicking tights, which she told me dried fast.

Where to go isn’t a problem limited to amateurs, either. During the 2005 London Marathon, Paula Radcliffe stopped on the side of the racecourse to relieve herself — in the sight lines of a media truck — and then went on to win the race. Before the 2013 Boston Marathon, both Shalane Flanagan and Kara Goucher didn’t have time to get to a Porta-Potty before the start, so they asked race officials to block the view from the crowds at the start. The officials obliged, using their bodies as a shield.

Now a new solution may soon be available: the Gotta Go running skirt. Skirt Sports, the company that makes the product, plans to release the Gotta Go on a limited basis at the end of May. It’s a version of its running skirt that includes what the company calls “a trap door and relief hatch.”

To release the hatch, “You lift the skirt up, open the Velcro from the front, the flap comes down and there’s an opening that’s anatomically positioned,” said Nicole DeBoom, the founder and chief executive of Skirt Sports. The trap door is adjustable, to provide a personalized fit and accommodate women who want to wear sanitary napkins while running as well.

The idea for the product, Ms. DeBoom said, came from their customers, who complained about incontinence issues arising from pregnancy, childbirth or aging. She’d also heard from women who told her they wouldn’t drink anything before a race because they didn’t want to have to stop to relieve themselves — a potentially dangerous situation that could lead to dehydration and serious medical issues.

But really: Would anyone buy a skirt with a hole in it?

To float the idea, Skirt Sports put up a Facebook post on April Fools’ Day 2015 envisioning “some kind of magical skirt that knows when you’re about to pee and opens up,” Ms. DeBoom said. Some 2,000 female runners responded with their ideas about what they would use the skirt for, with relieving themselves and replacing tampons or sanitary napkins during heavy periods at the top of the list. That led to a Kickstarter campaign, which drew 800 supporters who pledged $75 each. Contributors will receive their Gotta Gos once they become available.

Ms. DeBoom says that if the feedback is positive, they’ll consider adding it to Skirt Sports’ regular line in both short and Capri length.

Though I’m not a huge fan of running skirts — the extra swishing bothers me — at least someone is working on a solution. Until then, I’ll keep waiting in long Porta-Potty lines, or hope I’ll be able to enlist a fellow runner to shield me should I need to peel off to the side of the road.

Or, I could always learn to do what the ultramarathoner Deborah Paquin learned to do: go standing up. She got the idea in the late 1990s, after getting stuck in a Porta-Potty at the start of one race then, in another, accidentally mooning a fellow runner. “I needed to find a better way,” she said. After a few mishaps, she found success “if I tilted my pelvis under a little and spread my legs wide enough and really engage my abs.” Personally, I’m not sure I’m up for the trial and error.

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Ask Well: Why Is Arthritis More Common in Women Than Men?

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Flu Shot During Pregnancy May Reduce Risk of Stillbirths

Flu vaccination during pregnancy may reduce the risk of stillbirth, a new study reports.

Researchers studied birth and maternal vaccination records for 58,008 pregnancies in Western Australia during the 2012 and 2013 flu seasons. There were 5,076 births to women who had had the flu vaccine at some point during pregnancy, and 52,932 births to unvaccinated mothers.

After adjusting for maternal age, socioeconomic status, diabetes, hypertension and other health and behavioral characteristics, they found that the risk of stillbirth was 51 percent lower in vaccinated women than in unvaccinated ones.

The researchers acknowledge that the study, in Clinical Infectious Diseases, is observational and does not prove cause and effect, and that the results may not be generalizable to other populations or other flu seasons.

The Centers for Disease Control and Prevention recommends the flu vaccine during pregnancy, but more than half of all pregnant women in the United States are unvaccinated.

The lead author, Annette K. Regan of the Western Australia health department, said that pregnant women go unvaccinated for two main reasons: they are unaware of its importance and their doctor does not recommend it, or they fear it will harm the baby.

“We hope,” she continued, “that these results show not only pregnant women but also their providers that flu vaccination is safe during pregnancy and has major benefits for both mother and infant.”

Endometriosis Tied to Increased Risk for Heart Disease

Women with endometriosis, especially those under 40, are at increased risk for cardiovascular disease, a new study has found.

Endometriosis, the growth of uterine tissue outside the uterus, may affect as many as 10 percent of women in their reproductive years. It can cause pelvic pain, painful menstruation, painful sexual intercourse and reduced fertility.

The analysis, in Circulation: Cardiovascular Quality and Outcomes, included 116,430 women free of heart disease and stroke at the start of the study. By the end of a 20-year follow-up period, 11,903 of the women had been given a diagnosis of endometriosis.

After adjustment for pregnancies, alcohol intake, physical activity, body mass index, diabetes and more than a dozen other factors, they found that women with endometriosis were 52 percent more likely to have had a heart attack, 91 percent more likely to have had angina and 35 percent more likely to have undergone coronary surgery.

This was a prospective study with a large sample and a long follow-up, factors which give it considerable strength.

“Women diagnosed with endometriosis need to adopt a healthy lifestyle,” said the lead author, Fan Mu, who was a student at Harvard and Brigham and Women’s Hospital when the work was done. “And they should be familiar with the symptoms of heart attack and angina, which are not the same in women as they are in men.”

The Only Girl at Her Science Camp

The author’s daughter pretending to run the controls of a space shuttle at NASA’s Kennedy Space Center.

The author’s daughter pretending to run the controls of a space shuttle at NASA’s Kennedy Space Center.

My 7-year-old daughter has pretend space launches in our living room. She loves Tinkerbell not because she has sparkly wings, but because she is a “tinker” fairy that can fix anything. Signing her up for summer camp should be a chance to simply let her grow and explore her interests as a budding scientist or engineer. Yet we are aware that as a Latina girl who dreams of being a NASA inventor, her path is unlikely to be smooth, and the deck remains stacked against her.

Last summer, I dropped her off at “Blast Off” camp at our local arts center, where kids created projects related to science and planets. Out of 10 children with little backpacks and beaming faces, she was the only girl. I smiled at her obvious excitement as I waved goodbye, but worried about the implications of how often the gendering of interests happens in the lives of our children. She may well be the only girl in the room for years to come.

Even as women have made uneasy but measurable strides professionally and earn more degrees over all than men, they remain under-represented in science, technology, engineering and math, known as the STEM fields, as evidenced everywhere from university classrooms to Silicon Valley board rooms. As Lorelle Espinosa notes, while women earned 57.3 percent of bachelor’s degrees in 2014, only 19 percent of bachelor’s degrees in engineering and just 18 percent of those in computer science were awarded to women. For minorities, the numbers are worse: In 2012, only 3.5 percent of STEM degrees went to Latina women (the demographic group to which my daughter belongs).

This paradox of increased gendering amid higher academic achievement in girls is visible early on in popular culture. Female characters are minimized and made less available in toy and clothing merchandising, particularly when it comes to action heroes. Toys are still often color coded and separated by aisle, with action and technology toys typically aimed at boys, and socially or emotionally oriented and role-playing toys aimed at girls, irrespective of crossover appeal. Rather than deciding for themselves the scope and use of a toy, children are being limited in their play by gender-specific designations and marketing. We’re simultaneously telling kids that gender doesn’t matter and opening doors professionally and educationally, but telling them it does matter (and in fact, more or less defines them) in the way they dress, in the toys they play with and how they engage with them, in the television programming they watch, and in the activities they pursue.

Children see far more than we give them credit for, and our culture barrages them daily with messages that say that pursuits like science or tech are for boys, and boys alone. We’ve purchased Carter’s brand science-themed pajamas available only in the boys’ section, and discovered last year that Pottery Barn Kids would not embroider a Star Wars backpack in pink (we tried to make a splash for kindergarten). Girls who do not fit today’s princess mold are often deemed tomboys, implying that their preferences are an incursion into a boy’s world, putting their budding femininity (however they wish to define it) at odds with their interests. No wonder so many girls shy away from STEM.

As parents, we choose what to support and what to purchase for our children. I often shop across departments and aisles, indifferent to what arbitrarily designated section I am browsing. While on the whole the choices for girls are narrow outside of sparkles and princesses, I am heartened by the uptick in clothing options that don’t pigeonhole children, like space T-shirts for girls introduced by Lands’ End and Hanna Andersson, or new lines of clothing meant to celebrate the broad interests of kids, like Let Clothes be Clothes and Princess Awesome.

Yet as my daughter is getting older and can read and intuit labeling, packaging and messaging, she has begun to question if it is alright to like something from the boys’ section, even if it is something as universal as science – and whether that is a threat to the particular girl identity she has crafted for herself. We know this is a long-term conversation and that it is our job to encourage our child not just to pursue her interests, but to move beyond the narrow confines of a manufactured girliness.

Womanhood in this complex world requires strength and poise, the confidence to blur the lines of what is acceptable to find one’s own path. As a woman of color with a doctorate, I know from experience that my daughter is likely to face presumptions and questions due to preconceived notions of who she is and her competence level. We must prepare her for this as well.

This summer, she is hoping to try robotics camp, or maybe a week on dinosaurs. While the make-up of her peer group at her chosen camp may not turn out to be ideal, I’m hoping she will learn from it and keep asking questions, and so will we.

Lara N. Dotson-Renta, a scholar of Spanish and French literature and cultural studies, is working on a book that traces the history of Puerto Rico through family narratives and shared experiences of womanhood.

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New York City Bill to Call For Free Tampons in Public Restrooms, Shelters and Jails

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New York City Council members are joining a growing national movement to improve access to feminine products, and this Tuesday will introduce proposals for free tampons and pads in city public restrooms, homeless shelters and correctional facilities.

“This has been so taboo for so long, that no one even thought about it,” said Councilwoman Julissa Ferreras-Copeland, who spearheaded local efforts with a pilot project providing free pads and tampons in a high school in Queens that is being expanded to include 25 schools. “It’s just been something that it has never been O.K. to talk about.”

In addition, Ms. Ferreras-Copeland, Councilman Ydanis Rodriguez and the Council speaker, Melissa Mark-Viverito, will also introduce a resolution calling on the state legislature to stop taxing sanitary products. The state does not tax groceries, prescription drugs or condoms, but it still taxes tampons and sanitary pads. Earlier this month, the New York State Assembly passed a bill eliminating sales tax on tampons and pads, but the measure has yet to pass the Senate.

The proposals by members of the New York City Council are the latest in a series of efforts around the country that activists call “menstrual equity” — a movement that calls for feminine products to be treated the same as toilet paper and other necessities that are typically not taxed or are offered free in public spaces. Chicago rescinded city taxes on sanitary products earlier this month, California lawmakers are pushing for an end to tampon taxes and Canada scrapped the taxes last year. Efforts to make sanitary products available free in public facilities are underway in Wisconsin and Ohio.

Ms. Ferreras-Copeland said she can foresee potentially making free menstrual products available in the city’s public hospitals, parks and recreational centers, and at youth and community programs.

A bill requiring the New York City Department of Correction to provide all female inmates with pads or tampons “immediately” upon their request, and at the facility’s expense, is meant to improve the current way of allocating sanitary products, which is done according to an arcane formula that allots 144 pads a week to every 50 inmates, council members said.

That works out to about 12 pads per woman per cycle, which may not be sufficient, council members said. If a woman needs more than that, she must purchase them at her own expense at the commissary. The bill calls for eliminating the formula and providing either pads or tampons, immediately upon request.

Councilwoman Ferreras-Copeland called the formula “ridiculous,” saying that every woman has different needs. “You don’t ration toilet paper or ask for permission for more toilet paper,” she said. “You shouldn’t have to for these products.”

What all these programs may cost is not entirely clear. According to one estimate by the advocacy organization Free the Tampons, the annual cost of providing tampons and pads at restrooms in schools and businesses is less than $5 a year per woman or girl.

A program announced just last week to install tampon and pad dispensers in 25 public middle and high schools in New York City is estimated to cost $160,000 for a year, including the cost of replenishing the supply of products, according to Ms. Ferreras-Copeland’s office.

Women “cannot participate in society without some sort of menstrual product,” said Jennifer Weiss-Wolf, a writer and lawyer from Maplewood, N.J., who is a leading advocate for lifting tampon taxes and providing sanitary supplies in public restrooms and schools. “As a society, we have an interest in insuring that girls don’t fall behind in school and women aren’t unproductive at their jobs simply because they can’t afford these products.”

Earlier this year Representative Grace Meng, Democrat of New York, convinced federal officials who oversee the Federal Emergency Management Agency (FEMA) to allow its homeless assistance funds to cover feminine hygiene products, after she noticed the grants could not be used to purchase sanitary pads even though they cover other basic necessities items like toothpaste and diapers. Sanitary products will be added to the list of allowable purchases beginning in April.

Ms. Meng has also introduced legislation that would allow employees to use flexible spending account funds to buy feminine hygiene products. Right now the monies can be used to cover certain medical items like prescription eyeglasses and bandages, but not sanitary pads or tampons.

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