Figure 4. Sequence of events determining who receives pediatric growth hormone treatment.

Ratios indicate male:female proportions at the various steps, with their respective references. The 2:1 male predominance among children receiving short stature evaluations at endocrine clinics results from the combination of gender-based referral biases by their primary care providers and gender-based biases of patient-families who directly seek specialist evaluation; the relative contributions of these two sources could not be quantified.