Human sexual development is conceived as a process, begun at conception and continuing throughout life. Infants, children, teens, and adults are all sexual beings. Indeed, "sexuality is a central part of being human" (SIECUS, 2004, p. 15). Although we know a great deal about sexual behaviors in adolescence and adulthood, childhood sexuality is a rather neglected field in sex research. A cursory glance at contemporary college-level lifespan developmental textbooks demonstrates solid coverage of sexuality during adolescence and throughout adulthood but scant attention to this topic during any of the prepubescent phases. Even studies of adolescent sexual behavior do not begin assessing participants until age 12 or later (Zimmer-Gembeck & Helfand, 2008). In contrast, there is a growing literature on problematic sexual behaviors during childhood, but unfortunately very few articles or books about normal childhood sexuality. As Lagerberg (2001) observed, "the sexual development of normal children is neither fully explored nor understood" (p. 368), and children's sexuality remains "a relatively uncharted area" (Friedrich, 2003, p. 107).
Why is there a paucity of research into normative sexuality development in childhood? Freud's (1965) concept of latency led to a denial of childhood sexuality for most of the twentieth century. Western society is profoundly ambivalent about human sexuality and continues to view children as innocent and asexual, lacking any sexual desires or thoughts or erotic interests (Heiman, Leiblum, Esquilin, & Pallitto, 1998). As a research topic, children's sexual behavior is challenging to study, especially in the United States. Much of the work in this area has come from the Scandinavian countries where attitudes toward sexuality are more permissive (Sandfort & Rademakers, 2000) and where institutional review boards and funding agencies place fewer restrictions on studying this topic. Parents are often reluctant to participate in studies of this topic, and children's capacities to provide self-report are limited. Much of younger children's sexual play happens in private or is viewed only by people who have opportunities to observe them in intimate situations or on a regular basis, while older children have been socialized to conceal their sexual activities. Retrospective reports have been used to assess the frequency with which young adults remember engaging in sexual behaviors as children (e.g., Goldman & Goldman, 1988; Haugaard, 1996; Haugaard & Tilly, 1988; Lamb & Coakley, 1993; Reynolds, Herbenick, & Bancroft, 2003; Ryan, 2000a). Given the difficulty inherent in remembering events of early childhood, however, retrospective investigations are of limited use for describing sexual behaviors during this phase of childhood.
These methodological factors contribute to the paucity of research on normative childhood sexuality. Yet there is great need for such information. Over the past 2 decades, we have seen increased attention devoted to problematic sexual behaviors brought about by research demonstrating a significant association between childhood sexual abuse (CSA) and subsequent sexualized behaviors (e.g., Kendall-Tackett, Williams, & Finkelhor, 1993). Since "abnormal" sexual behavior is regarded as a potential indicator of abuse, it is important to understand what is considered "normal" childhood sexuality. In addition, children and adolescents with sexual behavior problems, many of whom offend against other children, are a growing national concern (Longo, 2003). In an age when CSA is increasingly on our minds, it is important for counselors, leachers, and parents to understand what are healthy sexual development and common sexual behaviors and which behaviors are uncommon, potentially harmful, or might signal a child is being sexually abused or is at risk for abusing other children.
Our primary goal in this article is to review what is known about normative and nonnormative sexual behavior and knowledge among children 12 years and younger. Second, we review what is known about contextual influences on children's sexual behaviors. What is deemed "normal" sexual behavior is determined by social, cultural, and familial contexts (Elkovitch, Latzman, Hansen, & Flood, 2009; Frayser, 1994; Friedrich, Sandfort, Oostveen, & Cohen-Kettens, 2000; Heiman et al., 1998; Pithers, Gray, Busconi, & Houchens, 1998). Third, we use these findings to offer suggestions for how parents and other adults can provide sexual abuse prevention education while simultaneously promoting children's healthy sexual development. Children who do not know about these two topics--sexuality and body safely--are more vulnerable to sexual abuse (Wurtele & Berkower, 2010). Finally, we will offer guidelines for parents, childcare providers, teachers, and counselors about how to respond to normal and problematic sexual behaviors. Parents and professionals working with children frequently ask questions about the normality of children's sexual behaviors. They often want to know whether the behaviors are typical and to be expected, or arc an indication that the child has been sexually abused. More important, they want to know how to address children's sexual behaviors. We will provide guidance on responding to sexual behaviors and suggest ways adults can help children grow into happy, healthy sexual adults.
NORMATIVE SEXUAL BEHAVIORS IN CHILDHOOD
The outline of sexual development and educational needs is organized in the following way. The age range 0-12 years has been divided into four age groupings: 0-2, 3-6, 6-9, and 9-12. When considering sexual behaviors, any demarcation of specific age categories is somewhat arbitrary, and common behaviors overlap considerably, especially at the ends of each phase. As with any domain of development, there is substantial variability between children even of the same age. Thus, the age groups should not be seen as rigid dividing lines in the course of children's sexuality development.
For each age group, a general description of high- and low-frequency behaviors is provided. This is followed by tables listing Common Behaviors, Concerning Behaviors/ Signs, and Educational Implications. The Common Behavior section describes high-frequency behaviors that may be observed in children who are on the path to healthy sexual development. Concerning Behaviors/Signs describe low-frequency behaviors or clinical signs, suggesting a child requires redirection, adult intervention, additional sexuality education, possibly assessment by a mental or medical health professional, or in some instances reporting to child protective services.
It is important to note that the presence of concerning behaviors does not always indicate that a child has been sexually abused. A substantial minority (about 20-40%) of victims of CSA show no clinical symptoms (Bahali, Akgan, Tahiroglu, & Avci, 2010; Kendall-Tackett et al., 1993). In addition, many children who demonstrate problematic sexual behaviors do not have documented histories of sexual abuse (Silovsky & Niec, 2002). Research has found a number of other explanations for the presence of such concerning sexual behaviors. These include factors such as the child's exposure to sexually explicit material, overt sexuality in the home, opportunities to witness sexual activity, level of stress in the family, parental absence from home, family violence, child physical abuse or neglect, extent of cobathing and cosleeping with siblings or parents, maternal attitudes toward sexuality, and time spent in daycare (Friedrich, Fisher, Broughton, Houston, & Shafran, 1998; Kellogg, 2010). In addition, children's sexual behaviors are affected by the size of the family, the neighborhood in which they live, the age of their siblings, and their level of sexual interest, along with parental, religious, societal, and cultural norms and values regarding sex and sexuality (Johnson, 2009). Repeated exposure to incomprehensible sexual stimuli (e,, confusing sexual images in media) can also increase the likelihood that children will act out what they have observed. Although little is known about cultural contexts that influence children's sexual behavior, some research has found higher rates of sexual behavior reported by parents in other countries (e.g., Larsson, Svedin, & Friedrich, 2000). Our review, however, will primarily focus on research conducted in the United States.
For each age range, Educational Implications will provide readers with developmental guidance on how parents and caregivers can foster the sexual development of their children and how professionals working with children can respond to children's sexual behaviors. Guidance is offered for how adults can teach "sexual manners" to children in ways that are consistent with family and cultural values. Through sexual socialization, children learn what their society considers desirable for a male or a female to be or to do and which sexual behaviors are to be exhibited in public versus in private. Finally, we will provide a summary for each age range, to serve as a quick reference to problematic and normative behaviors for children.
Infancy and Toddlerhood (Birth to Age 2)
With regard to sexual development during gestation, males and females are anatomically similar until the 3rd month alter conception (Fogel, 2011). During the 2nd month, male fetuses produce large amounts of androgens, primarily testosterone, which cause the Wolffian duct system to transform the primitive gonads into the vas deferens, prostate, seminal vesicles, epididymis, and testicles. By the 3rd month of development, this continued action causes the development of the external genitalia (penis and scrotum). In contrast, the absence of large levels of testosterone in females results in the shrinkage of the Wolffian duct system, and the Mullerian duct system develops into the female reproductive system (King, 2009). So, interestingly, male and female embryos are identical during the first few weeks of development. Unless there is a high level of testosterone at a critical stage of prenatal development (7th week post-conception), nature has programmed everyone for female development.
Infants and toddlers will typically develop a capacity to trust and a sense of autonomy through interacting with sensitive and loving caregivers. Being held, touched, kissed, hugged, and snuggled allows babies to experience positive physical sensations associated with being loved. Indeed, Harlow's (1973) research confirmed that through such nurturing touch and body contact, human beings learn to love from a very early age. Frayser (1994) notes that this nonverbal communication between caregiver and infant becomes a critical component of a child's attitude toward his or her body, gender, and sexuality. Breastfeeding is one of the first social contexts within which the infant experiences intimacy (Frayser, 2003). This type of intimacy and emotional attachment between infants and parents can be the early foundation of more mature forms of physical intimacy that will develop later as part of healthy sexuality. By providing care in response to the infant's needs rather than according to the parent's agenda, parents can model and foster the development of empathy; the lack of which is a common characteristic of individuals who abuse others (Ryan, 2000b).
During the first few months of life, infants begin to discover their bodies. A boy discovers his penis between 6 and 8 months, and girls typically discover their vulvas at 10-11 months (Martinson, 1991). Babies often explore their genitals during diaper changes or bathing. This type of touching is not masturbation in the adult sense, but it is learning that when certain parts of the body arc touched or rubbed, something pleasurable occurs. When pleasant sensations occur, children may seek to repeat the behavior. Young children also touch, fondle, and rub their own genitals as a means of self-soothing and will often do this when going to sleep or when tense, excited, or afraid. Infant boys regularly have penile erections when awake (while coughing, stretching, urinating), and during sleep girls' vaginas are thought to lubricate just as often as boys have erections (Haffner, 2004). These are spontaneous, natural responses to touch, friction, or the need to urinate.
Redness, soreness, or reports of genital discomfort may alarm parents and caretakers into concerns that CSA has occurred. Kellogg, Parra, and Menard (1998) reported that in most cases where girls are brought to a physician with genital symptoms, the explanation is a normal finding or some nontraumatic disorder. Some children, particularly girls, may be prone to recurrent bladder infections, more commonly called urinary tract infections (UTIs), which may have a number of causes, including the repeated use of soap, bubble baths, and shampoo, which can irritate the urethra and wash away the protective mucus layer.
Toddlers exhibit much curiosity about their own bodies and other people's genitals, especially their parents' genitals (Schuhrke, 2000). Children begin to learn the differences between males and females and start identifying themselves as either boy or girl. This awareness is called gender identity. By the time they are 2 or 3, most children can identify themselves and the people around them as either female or male.
Implications for Sexuality Education/ Developmental Guidance
One of the best ways parents can keep their children sexually safe and healthy is to have frequent discussions with their children about sexuality starting when they are toddlers. Often the easiest place to start sexuality education is by teaching children the correct names for their genitals. By age 2, most children know the names of their nonprivate body parts, but very few learn the names for their genitals. Kenny and Wurtele (2008) found that while approximately 90% of both English- and Spanish-speaking preschoolers knew the correct names of their nongenital body parts, very few children (only 10%) knew the correct terms for penis, breasts, and vulva. Slightly more children (25%) knew the correct term for buttocks, but none of the Spanish-speaking children knew the correct terms for breasts, penis, or vulva. Children in this study did no better than children in surveys conducted in the early 1990s (e.g., Wurtele, 1993; Wurtele, Melzer, & Kast, 1992), suggesting that little progress has been made in parents' efforts to teach their young children the correct terms for the genitals. Teaching proper names for all body parts helps children develop a healthy, more positive body image. As Honig (2000) stated, it gives children "naming power" just as they have the power to name other things in their environment (e.g., toys, books, characters, etc.). Indeed, several experts have recommended that parents teach their young children the correct names for the genitals (American Academy of Pediatrics [AAP], 2011; Honig, 2000: Wurtele, 2010). The teaching of genital body parts also allows for a discussion of the differences between boys and girls.
This knowledge also provides the necessary foundation for CSA prevention education. Successful disclosure of abusive incidents relies partly on the child's ability to describe inappropriate activities involving the genitals and to correctly label the genitals. When children disclose CSA using incorrect or idiosyncratic terminology (e.g., "She touched my weiner," or "He kissed my VJPJ"), they may not be understood and are thus unlikely to receive a positive, supportive response to their disclosure. In contrast, disclosure using correct terminology is more likely to be understood, resulting in a more positive outcome for a child (e.g., by ending the abusive situation and obtaining therapeutic assistance for the child). Furthermore, children who lack sexual knowledge may be more vulnerable to sexual abuse. Some sexual offenders avoid children who know the correct names for their genitals, because this suggests that the children have been educated about body safety and sexuality (Elliot, Browne, & Kilcoyne, 1995). One convicted offender (who had assaulted 75 children before he was caught) reported that when children knew the correct terms for their genitals, he would leave them alone (Sprengelmeyer & Vaughan, 2000).
At this age, children learn through hands-on exploration, including their own body parts. During diaper changes a boy may grab his penis or a girl may touch her vulva. Not only can parents allow their babies to touch their genitals during diaper changes, they can use this teachable moment to name the body parts ("That's your penis"). Once a boy discovers his penis, he may touch it or hold it, often in public. Usually alter age 3, children are old enough to understand that even though it feels good, self-touching should be done in private. Caregivers can help children begin to comprehend the difference between public and private behaviors and that certain behaviors, such as picking one's nose or touching one's genitals, are best done in private.
Should toddlers ask where babies come from, it is best to offer simple answers or information. A response such as, "From the mommy's belly" may be all that is needed to satisfy the child's curiosity at this age. Keep language simple and comprehensible to the child. However, parents are discouraged from providing inaccurate information such as "God [or the stork] brought you to us" or "We got you at the hospital." This erroneous information only impedes later sexuality discussions.
Most children from birth to 2 years will be curious about and evidence some exploratory behavior toward their genitals and at the later end of this age range may even desire to look at their genitals or those of another while that person is urinating or undressing. As children move into toilet training, their inquiries about private parts usually increase. Both genders will touch their genitals for pleasure, and this behavior should not be shamed or discouraged. Boys will experience erections and girls may have vaginal lubrication, both of which have a purely biological basis. A primary educational goal for this age range is the teaching of proper terms for all body parts including genitals to lay the foundation for subsequent sexuality education. Responding to questions regarding pregnancy and sexuality honestly but simply is encouraged. Physical contact with young children is encouraged; a warm, sate, loving environment is critical to the child's feeling of safety and security.
Early Childhood (Ages 3-6)
By age 3, children have become quite familiar with their own bodies. Children in this age group tend to play together, and their natural curiosity about bodies now extends to other children's and adults' bodies, particularly their genitals. This is the phase of life when overt sexual behaviors are most likely to be observed. Friedrich, Grambsch, Broughton, Kuiper, and Beilke's (1991) administration of the Child Sexual Behavior Inventory (CSBI) to more than 1,000 mothers of children aged 2-12 years showed that sexual behaviors reach a peak from 3 to 5 years and then decrease in frequency until puberty. High-frequency behaviors as reported by parents include exhibitionism (e.g., showing genitals to others, wanting to be naked), voyeuristic behaviors (e.g., looking at people undressing, toileting, or while nude), behaviors related to personal boundaries (e.g., standing or sitting too close to others, cuddling with familiar people), and self-stimulating behaviors (e.g., touching genitals in public and at home). From this list, solitary, self-stimulating behaviors are most frequently observed (Elkovitch et al., 2009).
Nearly all young children touch and explore their genitals. They do so by using their hands or objects (e.g., toys, stuffed animals, blankets) or by rocking against a stuffed animal or rubbing against furniture. Preschool children may experiment by sticking their fingers or other objects in their vagina or rectum; usually this causes pain or discomfort, and the behavior stops. Boys engage in genital touching more often than girls. For example, in Friedrich et al.'s (1991) normative sample of children, 67% of 3- to 5-year-old boys and 55% of girls were reported by their mothers to engage in genital touching at home; 39% of boys and 19% of girls touched their genitals in public (Larsson et al., 2000). Preschool teachers reported observing a lower frequency of genital touching than do parents (Larsson & Svedin, 2002; Lindblad, Gustafsson, Larsson, & Lundin, 1995; Lopez-Sanchez, Del Campo, & Guijo, 2002). For example, only 5% of a sample of preschool teachers reported observing 3 to 6-year-old children engaging in genital touching, as compared to 43% of the parents of these same children (Larsson & Svedin, 2002).
As children begin interacting with other children, they become more social and often physical in their interactions. They may begin mimicking adult affectionate behaviors like kissing and hugging or holding hands. In many cultures, kissing and hugging between familiar adults and children is encouraged and is a frequent part of greetings and goodbyes. For example, children may be encouraged to kiss grandparents goodbye and extend this to others in their life. Children in this age range may express emotions physically (hug someone when they are happy, hit someone or something when they are angry) and may seek hugs and kisses from familiar people. An awareness of appropriate physical boundaries is not yet formed at this age, so children will often stand or sit very close to familiar people.
Preschool children also display curiosity about adults' bodies and bodily functions. They may want to watch grown-ups going to the bathroom or touch an adult's genitals. In particular, children who are breastfed or witness younger siblings being breastfed may be accustomed to such close contact with a woman's breasts and may try to touch them when being hugged or held. Martin and Luke (2010) found that mothers allowed their daughters (age 3-6 years) to see them naked more than their sons. These authors suggest that these opportunities to view their mothers' bodies may prompt girls to ask questions of their mothers as to why their own bodies look different from their mothers and thus provide more opportunities for mothers to provide daughters with sexuality information.
Touching their mothers' breasts or attempting to touch other women's breasts is a common behavior among young children both at home and at preschool (Friedrich et al., 1991; Lindblad et al., 1995; Rosenfeld, Bailey, Siegel, & Bailey, 1986). Almost half of the children in Friedrich et al. (1991) touched their mothers' breasts, and in a survey of preschool staff 36% of preschoolers attempted to touch a woman's breast (Davies, Glaser, & Kossoff, 2000). Parents of 2- to 4-year-olds reported that 90% of children had recently touched their mothers' genitals and/or breasts and approximately 60% had touched their fathers' genitals (Rosenfeld et al., 1986). These findings are confirmed in a study by Davies and colleagues (2000), who interviewed 58 preschool staff regarding their observations of sexual behavior among preschool children. The preschool staff commonly observed children exhibiting curiosity about genitals including children touching their own genitalia, attempting to touch a woman's breasts, looking at another child's genitals, and showing their own genitals to others.
Preschoolers are especially interested in the physical differences between boys and girls. Given the opportunity, young children will play games that allow for sexual exploration with other children. "Sex" play is a very common phenomenon among this age group (e.g., playing "doctor" or "mother and father," exposing parts of one's body to each other, the "I'll show you mine if you show me yours" game) (Rutter, 1971; Sandnabba, Santtila, Wannas, & Krook, 2003). In a longitudinal study of early childhood peer sexual experiences, Okami, Olmstead, and Abramson (1997) found that almost hall of the sample of adults reported sex play with peers before age 6. These games usually occur between children (sometimes cross-gender but mostly same-gender) close in age (Lamb & Coakley, 1993). In their sample of 3-to 6-year-old Swedish children, Larsson and Svedin (2002) found that 37% of boys and 48% of girls were reported by their parents to engage in "doctor" games. Similarly, more girls were observed playing "doctor" than boys in a Finnish day care (52% vs. 35%; Sandnabba et al., 2003). These activities are normal ways for children to explore physical differences between males and females in the same way they explore gender roles and adult behaviors (e.g., playing house).
Given that sexual play is quite common in children between the ages of 3 and 6 years, it is important to understand the scope of this behavior. Typical characteristics of sexual play at this age are the following (Davies et al., 2000; Friedrich, 2007; Gil, 1993; Hall, Mathews, & Pearce, 1998; Heiman et al., 1998; Hornor, 2004; Johnson, 2009; Kellogg, 2010; McKee et al., 2010; Okami et al., 1997; Wurtele & Berkower, 2010):
* Appears exploratory and spontaneous (unplanned, can occur in the context of other play)
* Occurs from time to time (infrequent)
* Is mutually consented to (one child does not always initiate it), and not coercive
* Happens between children who play together often and are very familiar with one another (siblings, cousins, or friends)
* Occurs between children who are similar in age, developmental level,
and status (actual or perceived power)
* Is fun, playful, and light-hearted; not accompanied by high levels of fear, anger, aggression, coercion, or anxiety; and not focused on sexual arousal
* Behavior ceases when caregivers intervene and ask children to stop
* Children engaging in this play can be easily diverted to other activities
* Appears voluntary between all children (no child reports being upset or uncomfortable with it)
Concerning behaviors at this age range include the following (Davies et al., 2000; Friedrich, 2007; Gil, 1993; Hall, Mathews, & Pearce, 1998; Heiman et al., 1998; Hornor, 2004; Johnson, 2009: Kellogg, 2010; McKee et al., 2010; Okami et al., 1997; Wurtele & Berkower, 2010):
* Sex play involving children of different age (4 years apart), size, status (actual or perceived power), developmental level, and between children who do not know each other well
* Type of sexual activity (repeated object insertion into vagina and/or rectum, oral--genital contact, imitation of adult sexual activities, sexual behaviors with animals)
* Dynamics of play (play is frequent, intense, and may have a compulsive quality; coercion, threat, bribery, aggression, or dominance accompanies the sexual activity)
* Causes harm to child or others: results in emotional distress or physical pain or injury Behaviors that appear to resemble adult sexual activity (imitating or attempting vaginal or anal intercourse with another child, oral--genital contact, tongue kissing)
* Behaviors are frequent and persistent, and child becomes angry if distracted from them
* Unable to redirect child from the behavior (i.e., behaviors continue even after requests to stop)
* Interferes with normal childhood activities
* Uses physical and/or emotional coercion to convince another child to engage in sex acts
* Uses intimidations or threats to ensure child keeps the activity a secret
In summary, normative sexual play is consensual; there is no emotional or physical coercion involved, and it is usually carried out with children of similar age, size, and status. Normative sexual play is usually spontaneous and includes pleasure, joy, laughter, embarrassment, and varying levels of inhibition and disinhibition (Shaw, Lewis. Loeb, Rosado, & Rodriguez, 2000). In contrast, problematic sexual play involves dominance, coercion, threats, force, aggression, compulsivity, secrecy, and advanced sexual behavior. Wurtele and Berkower (2010) noted that it is just as important for adults to respond supportively to children's "normal" sexual behaviors as it is for them to respond to problematic sexual behaviors.
Children this age have lots of curiosity about sexual topics, and many will ask endless questions about bodies and bodily functions ("How come my sister doesn't have a penis?"), breasts ("Why are your breasts so much bigger than mine?"), reproduction ("Where do babies come from?"), pregnancy ("How did the baby get in her tummy?"), and birth ("How does the baby get out?"). Their interest in sexuality can also be seen during play, as they may include genitals when drawing nude figures or undress dolls to see their genitals. Children may also be very interested in the breeding behavior of animals. As children learn about baby animals, they may inquire about where they come from, how they are made, and so on. Observation of animals mating (on television, in printed materials, on a visit to a farm or zoo) may also spark questions about reproduction. They may be acutely aware of the gender of animals and inquire whether the dog has a penis or vulva, once taught these names.
As children become aware of social rules regarding sexual behavior and language, they may test the boundaries and family rules by using what preschool teachers often call "toilet talk" (Chrisman & Couchenour, 2002). These authors describe how one preschooler zipped through the entire classroom chanting, "Poopy, poopy, poopy." Soon all the students were echoing "poopy" and laughing uproariously. Preschoolers frequently use words that refer to bowel movements and urination, often talking about "poop" and "pee." As they are exposed to other children and learn from them, they may purposefully use words that they know are not correct (e.g., the 6-year-old child who returns from school and informs his parents that breasts are really "boobs" because his best friend told him this).
Between ages 4 and 6, many children begin developing a sense of modesty and start expressing a desire for privacy. Even in homes where nudity is common, children often go through a "modesty stage" where they seem uncomfortable changing in front of their parents or walking around naked (Haffner, 2004). Parents should encourage children to seek privacy while bathing or dressing and again refer to private versus public behavior. Johnson, Huang, and Simpson (2009) asked 500 mental health and child welfare professionals for maximum acceptable ages for siblings to jointly engage in certain family practices related to hygiene, affection, and privacy. These guidelines are provided in Table 2.
As children age, they begin to have more contacts outside the family and thus interact more with peers under adult supervision (e.g., at preschool, lessons, classes, during play-dates). As children form relationships with others outside their family, they begin to learn to recognize some peers as friends and others as people they don't like. Friendship preferences develop, and children begin talking about who is their friend and who is not, often using terms such as "nice" and "mean" to describe peers. In fact, some preschoolers may even describe having "boyfriends" and "girlfriends" of the same or opposite gender. Their activities with these special friends are usually limited to hand holding, hugging, and kissing and are based on their notions of adult relationships. Preschoolers may become very attached to a parent, of the same or opposite gender, often expressing desires to "marry" that parent when they grow up.
By preschool, most children have developed a strong sense of being a boy or girl. This awareness, which develops by age 2 or 3 (Kohlberg, 1966), is called gender identity, our internal sense of being male or female. Most children do not develop a sense of gender constancy,, or full understanding of the permanence of their gender (e.g., a girl knows she will always be a girl) until age 6. The majority of children are very proud of being whatever gender they are and are secure in their gender identity. For a small minority of children, their sense of who they are as a person does not match their physical body; a psychiatric condition referred to as Gender Identity Disorder (GID). The exact prevalence of GID is unknown; however, a fair amount of cross-gender behavior is present in young children. Moller, Schreier, Li, and Romer (2009) reported that cross-gender behaviors are seen in up to 6% of young boys and 12% of young girls. Persistent signs of GID should be closely monitored and may require professional attention.
Children also begin to associate certain behaviors, called gender roles, with being male or female. Maccoby (1998, 2002) described how play themes and play styles differ by gender, beginning at age 3, resulting in two distinct subcultures or social worlds of boys and girls. Girls typically engage in themes related to family, school, adornment, or nurturance, whereas boys are more likely to act out themes of action, heroism, and danger. Girls prefer to play inside and in pairs, show greater cooperation and concern for their partners' needs, and play in close proximity to adults. Boys tend to play in large groups, outside, are more physical (rough-and-tumble play), and avoid proximity to adults. As Chrisman and Couchenour (2002) cautioned, the differences found in the play of girls and boys should not lead to stereotypes such as "boys don't like to play house" or "girls don't like physical play" (p. 44). Instead, preschool children should be encouraged to explore a full range of play. Preschool boys may dress up in girls' clothes or a girl may pretend to be a "daddy." These cross-gender behaviors are only of concern if they are accompanied by gender confusion (e.g., a boy insists he really is a girl).
Although children often mimic adult-like behaviors (e.g., talking on cellular phone, house cleaning, cooking, or typing on computer keyboard), displaying adult sexual behaviors is infrequent. Adult-like sexual behaviors (e.g., putting mouth on others' genitals or a doll's genital area, trying to insert penis into vagina or rectum, asking to engage in sexual acts, masturbating with objects, inserting objects in own or others' vagina or rectum, imitating sexual behavior with other children or dolls, tongue kissing) as well as intrusive or aggressive sexual behaviors (e.g., forcing child to take off clothes and play "doctor") are very rare in this age group (typically less than 3% in community samples; Friedrich et al., 1991) and in less than 2% of preschool samples from England and Finland (Davies et al., 2000; Sandnabba et al., 2003).
Implications for Sexuality Education/ Developmental Guidance
This stage of development presents ample opportunities for fostering children's sexuality development and to teach body-safety rules to prevent sexual victimization. A primary goal for this age group relates to teaching personal boundaries and body ownership. Helping children understand that their bodies belong to them and that they are in control of and responsible for their bodies is an important message to communicate starting at this age. Most important is to help children understand how the public/private distinction works in their culture (McKee et al., 2010). Children can learn that private parts are to be kept private and should not be touched by others or shown in public. This rule helps children understand the need for privacy when dressing, toileting, and bathing. Teaching children that no one should touch their private parts, except a doctor or parent to keep them clean and healthy, begins to establish boundaries and teaches children about body safety. Without being taught, few young children naturally know that it is wrong for other people to touch or look at their genitals (Wurtele & Owens, 1997).
There are bound to be many teachable moments during these years, since preschool-age children are naturally inquisitive. Bathing and toileting offer multiple teachable moments to use proper terms for the genitals ("Did you wash your penis?" or "Be sure to wipe front-to-back, from your vulva toward your anus"; Wurtele, 2010). Children at this age will also engage in sell-touching, since it feels good. This may happen when a child is watching television or is excited or bored. Caregivers can use this occurrence as a teachable moment and say, "I know touching your penis feels good, but we only do that in a private place, like a bedroom. If you want to watch TV with the family, you are going to have to stop." Instead of punishing their children for normative sexual behaviors (like self touching), caregivers can use redirection or gentle distraction. Curiosity about parents' bodies is common at this age too, and children may seek out opportunities to view their parents naked. Wurtele (2010) cited the example of a young girl who wanted to take photos of her father while he was showering. The parent used this as a teachable moment by reminding the child that private parts are to be kept private and that no one should ever lake pictures or movies of her while she is naked. This intense interest in body parts and functions provides parents with ample opportunities to share their culture's notions about boundaries (both psychological and physical). As part of sexual socialization, family members define and set limits regarding which areas of the body can and cannot be touched and clarify which activities should be done in private versus public.
If children are seen displaying sexual behaviors during this stage, parents and caretakers may follow a number of guidelines. Most important is to stay calm and not react in haste. For example, the parent or caretaker who walks in on two 6-year-olds playing "doctor" can say, "Hey, it looks like you two are checking out one another's private parts. It's okay to be curious about private parts, but you know we don't show our private parts to other people. Let's get dressed and talk about this." The use of open-ended questions (e.g., "What game were you playing?" "How did you learn about this game?"), can be utilized at this time to gain more information and to understand the activity from the child's perspective. Seeing the behavior from the child's point of view will help parents understand that the behavior is not erotically focused but is more likely to be motivated by curiosity. An opportunity like this, although potentially uncomfortable for the parent, can serve as a perfect teachable moment for discussing healthy boundaries and reinforcing body-safety lessons. ("Remember our rules about private parts? No one is allowed to touch or look at your private parts, and it's not okay for you to look at or touch somebody else's private parts. This means you should never touch your friend's private parts, and your friend should never touch yours. It's okay if you want to play the doctor game, but just keep your clothes on." [Wurtele, 2010]). It is also helpful to determine what might be motivating the child's sexual behavior. If the behavior is related to curiosity, then provide information that is appropriate to the child's age and developmental level. ("If you're curious about how boys' and girls' private parts are different, I have some picture books we can look at. Would you like to do that?" See Appendix A for age-appropriate resources).
By 6 years of age, most children have a limited but growing fund of sexual knowledge. Most children by this age understand the physical and anatomical differences between boys and girls. They begin to respect the privacy of others and may knock on doors before entering and close their own doors while undressing or toileting. They may even request privacy, by asking the parent to leave the bathroom while they are showering or dressing. Children begin to understand that some touching is not okay; in addition to touches that feel bad (hitting, kicking, biting), they may not want to be hugged or kissed by relatives as frequently, and they begin to express their own desires. Most children enjoy being a boy or a girl and begin to embrace activities or hobbies often associated with that gender. Parents and caregivers can continue to model appropriate behavior and share positive messages about both genders.
Parents' and caregivers' major roles in this stage are to continue to reinforce concepts that have already been discussed as well as continue to be open to sexuality discussions. As much as parents are comfortable, they may begin to provide age-appropriate explanations for reproduction and birth as the child's curiosity grows. Children may have greater understanding of where babies come from, particularly if there has been another child born into the family. Although their understanding of adult sexual functioning is limited, they may begin to learn basic concepts of procreation and reproduction such as the egg and sperm and that babies grow inside the mother.
Martin and Luke (2010) found that mothers of young children (aged 3-6 years) talk more to daughters than sons about romantic relationships, reproduction, and moral issues around sexuality, suggesting that they may need encouragement and guidance from counselors in also holding these discussions with their sons. Also, since children at this age are spending more time with others outside their home, they may begin to bring home slang terms or incorrect terminology learned from peers. Particularly if a child is in daycare, he or she may be exposed to children who vary in their sexual knowledge and behavior. Debra Haffner, author of From Diapers to Dating, told of 6-year-old David asking his father, "Dad, do you and morn f***?" She recommended calmly asking "Where did you hear about that?" followed by "What do you think that means?" (These types of questions will give parents an idea of what their children are really asking and help give an indication of what their children are ready to learn.) Then give the child a short, simple answer and ask him not to use those words again. Haffners' suggested response: "That's not a very nice term for adults making love. It's a word that most adults don't like, and I hope you won't use it again" (p. 130).
According to Friedrich and colleagues (1998), sexual behavior in children peaks at around age 5 for both boys and girls and then tapers off for the next 7 years. Most preschool-age children are naturally inquisitive about their environment and the people in it. They begin to recognize gender differences and may experiment with touching their own genitals as well as those of other peers and adults. When this behavior occurs within the context of mutually agreed-upon play, with close-in-age siblings or peers, it should be understood as normative, although it still provides the opportunity for teaching about private parts, boundaries, and appropriate touching. There are many sexuality and prevention concepts that can begin to be taught to children in the preschool age. To help children recognize potentially abusive situations, it is important to avoid using abstract or developmentally inappropriate messages (such as telling them to "trust their feelings" or using the "good touch/bad touch" teaching approach shown to be ineffective in Wurtele, Kast, Miller-Perrin, and Kondrick, 1989). As an alternative, the concept that children are "bosses" of their bodies and no one has the right to touch them in any way, particularly not their private parts, is a better approach (Wurtele, 2007). In addition, the idea that touching oneself may feel good and pleasurable can be discussed, and parents can emphasize rules related to privacy and private spaces in the home. Parents may wish to participate in sexuality education programs or parent support groups or enroll their children in sexual abuse prevention programs which often begin to be offered at this age. Counselors can provide recommendations to daycare centers and schools regarding effective personal safety programs (see Kenny & Wurtele, 2010, and Wurtele & Kenny, 2010a, for program guidelines).
Early Elementary School Children (6-9 years)
Freud (1965) described middle childhood as a period of "latency," when sexual drives are dormant and children show little interest in sexual issues. Based on their surveys of four societies--the United States, England, Sweden, and Australia--Goldman and Goldman (1982) concluded that there is no latency period in sexual development as Freud hypothesized. Although school-age children do engage in less overt behavior at this time (Friedrich et al., 1991), they continue to be very interested in sexual issues. But because they have developed a sense of modesty and are aware of social stigmas and the taboo nature of sexuality, they are less likely to engage in sexual behaviors where they can be observed by others, particularly adults. Even with this inhibition, mothers still observe their children exhibiting sexual behaviors. For example, 13% of 6- to 9-year-old boys were still touching their genitals in public, 40% did so at home, 20% tried to look at people nude, and 14% were very interested in girls (Friedrich, 1997). Girls also exhibited sexual behaviors: Twenty percent had been observed touching their genitals, and 14% were very interested in boys.
Curiosity about physical differences continues during this phase. They continue to sneak pecks at siblings or parents when undressing or bathing and may need to be reminded about privacy rules. Kindergarten, first-, and second-grade teachers report observing a lair number of voyeuristic behaviors (e.g., peeking under the bathroom stall at other students; Kaeser, DiSalvo, & Moglia, 2000). Sex play also continues throughout these early elementary-school years. Children often compare genitals with same-aged peers and show interest in touching the genitals, breasts, or buttocks of other same-age children. When they have the opportunity, children engage in both opposite-gender and (mostly) same-gender sex play. Some try inserting objects in their own genitals/rectum and do this out of curiosity or exploration. The major difference between sex play of preschoolers and 6- to 9-year-olds is that the older group takes better care to ensure they won't be discovered. Reynolds et al. (2003) reported that 58% of their sample of college women and 64% of men recalled engaging in sexual games during elementary school, but only 24% of these experiences were ever discovered by adults.
Although developmentally children begin to gain greater independence and autonomy from caregivers, physical intimacy is still important to 8- and 9-year-old boys and girls (Rademakers, Laan, & Strayer, 2000). Children at this age enjoy romping with family members and peers and also like to cuddle with people along with toys, dolls, and stuffed animals. Children say that cuddling (hugging, kissing, and sittling on someone's lap), made them feel "sale, nice, cheerful, fun, kind, and comforted" (Rademakers, Laan, & Strayer, 2003, p. 123). Caregivers are encouraged to meet children's needs for cuddling, as this physical contact is still important and desired by children and critical to their sense of safety and security.
During the early grade-school years, children are busy making friends and developing their social skills. Children begin to choose their own friends and begin spending more play time with their peers. The preference for same-sex and similar-aged playmates, friends, and school groups continues throughout this period. Children in this age range also tend to maintain a fairly rigid separation between males and females. This is the age when many children start to make comments about the opposite gender. Maccoby (1998) reported that in middle childhood boys increase their use of inappropriate language, often talking about girls' bodies, ridiculing girls (e.g., teasing about breast development), and uttering sexually explicit terms or making demeaning comments. Although the two sexes tend to remain separate during this period, they seem to be very aware of each other, and both boys and girls tease each other about having boyfriends and girlfriends or being "in love" (Chrisman & Couchenour, 2002). As evidence that sexual interests arc not dormant during this lime, Wallis and VanEvery (2000) described elementary-school playground kissing games involving girls chasing boys for kisses and boys chasing girls for kisses. These types of games are evidence that children do exhibit (hetero) sexual behaviors in public settings and that schools are not "asexual." These teachable moments also provide opportunities for school staff to draw attention to the public/private distinction, sexual diversity, and also respectful sexual behaviors.
It is common at this age for children to turn to peers, media, and other sources (e.g., the internet) for information about sex. Almost half of children ages 6-9 use the internet daily for an average of 28 minutes (Kotler, 2008). They begin to view websites, movies, or television shows, and to listen to music that often has sexual content. Children may ask fewer questions about sexuality from their caregivers, but they still have lots of curiosity and need information about sexuality. They begin to understand more complex ideas with regard to sexuality and begin to comprehend intercourse as an activity apart from making a baby.
By 7 or 8 years of age, most children will have developed an established sense of gender identity and gender constancy. The process of gender role socialization is heightened during this period. While cementing their self-concept of gender as male or female, children often show a strong preference for gender-typed clothing, toys, and activities (Martin & Ruble, 2004).
They also like playing games with children their own age that involve sexual behavior (such as playing "family") and simulating roles of mothers and fathers. As they move through this age, children give up on wanting to "marry" their mother or father and turn their attention outside the family. Gender role identification is generally stabilized during this age, as girls become closer to their mothers and boys to their fathers. According to Bussey and Bandura (1984), children begin modeling their behavior after same-sex role models around the age of 6, due to a desire to behave in a way that is consistent with his or her gender. Children engage in greater gender-stereotypical behavior and activities than before, leading to a gender divide.
As they move out into a more social world, children will learn (often incorrectly) about sexuality from their friends. Children giggle with their friends about "private parts," tell "dirty" jokes, and search through books and the internet for "sex stuff." Parents may see an increase in children's use of sexual or obscene language, often done to test parental reaction. In fact, Kaeser et al. (2000) found that the most common "sexual" behavior observed by teachers of kindergarten, first-, and second-grade children was sexual communication (students making sexual comments verbally or in writing to each other). Jokes about bodily functions--such as burps, farts, urination, and defecation--are common as well and produce uproarious laughter.
In contrast to earlier ages, children ages 6-9 show a decrease in overt sexual behaviors including behaving like the opposite sex, playing with their own private parts in public, playing with their own private parts too much, thinking about sex too much, or wishing to be the opposite sex (Meyer-Bahlburg, Dolezal, & Sandberg, 2000).
Implications for Sexuality Education/ Developmental Guidance
The AAP (2011) recommends that parents help their children understand healthy sexuality because lessons and values learned at early ages are likely to remain with them as they grow to adulthood. According to the Sexuality Information and Education Council of the United States (SIECUS), "parents and caregivers are--and ought to be--their children's primary sexuality educators" (SIECUS, 2004, p. 13). During these middle childhood years, it is important that parents and caretakers continue to provide information about sexuality, even if a child does not ask for it. At these ages, children may ask fewer questions but still have lots of curiosity and need information about sexuality. Parents can utilize teachable moments or opportunities that occur every day to introduce sexual topics or review concepts previously discussed. For example, watching television as a family can provide many opportunities to discuss sexual topics.
Although parents are the primary sexuality educators of their children, research has shown that parents often feel inadequate in discussing many sexual topics. In El-Shaieb and Wurtele (2009), two topics (masturbation and nocturnal emissions) were difficult for parents to talk about with their children, and 25% of parents indicated that they would never discuss these two topics with their children. A large body, of research has revealed that parents and their children commonly have difficulty talking with each other about sexuality. In addition, many Latino cultures have a taboo against discussing sexuality, and parental communication regarding sexuality is often lacking (Kenny & McEachern, 2000). Thus, there may be a need for educational efforts outside the home as well. It is important that schools provide sexuality education programs, which most parents (91%) favor (Chappell, Maggard, & Gibson, 2010).
Parents can also utilize a variety of books that assist with discussing sexual matters. These books can be read with children, or children can look at them on their own, as many children feel more comfortable exploring or reading them in private (see Appendix A). Caregivers are encouraged to check back in with children after they have had some time to read to answer questions or clarify any information.
As children age and arc in contact with more diverse individuals, they may begin to come into contact with individuals with different sexual orientations. For example, a child may return from school talking about Cate and her "'two mommies." This provides an opportunity for parents to explain differences in sexual orientation. Sexual orientation refers to "whether an individual is more strongly sexually attracted to members of his or her own sex, the opposite sex, or other sexes" (Goldberg, 2010, p. 127). Counselors may be able to provide guidance to parents as they explain these concepts to their children. When adults model and expect appreciation of differences and similarities, it will be more natural for children to adapt these attitudes as well.
Children between the ages of 6 and 9 years generally show a decrease in overt sexual behavior, and relationships are centered around same-sex friendships and identifications. Children begin to formalize their sense of self as a boy or girl. They remain affectionate with parents, but peers are often included in their displays of affection (i.e., hugging, kissing, holding hands), as they begin to move away from the family as their primary influence and toward peer groups. This shift may also contribute to the use of vulgar terms or inappropriate references to sexual material, which has been learned from peers. Children will continue to be curious about others', nudity and may take advantage of opportunities to see others naked or undressed but will desire increased modesty for themselves (i.e., requesting privacy while changing clothes). Parents will need to continue to monitor their child's understanding of sexual matters and will want to find opportunities to introduce sexuality education on emerging topics of interest to children in this age range. Caregivers will want to begin to discuss with their children several more mature themes, such as reproduction, sexually transmitted diseases, sexual orientation, and sexual respect, along with the impending changes that accompany puberty. Counselors may play an important role in helping parents communicate this information to their children, as many parents may feel unprepared or embarrassed. Counselors can recommend "best practices" for diverse family structures (see SIECUS, 2002, for a review of innovative approaches to increase parent--child communication about sexuality).
Preadolescence and Early Adolescence (9-12 years)
Nine- to 12-year-old children are in the early stages of adolescence. This phase of life includes the first two substages of sexual development identified by Sharpe (2003)--Substage I: Preadolescence (occurring before 10 years of age) and Substage II: Early Adolescence (between 10 and 13 years). Preadolescence is the time of adrenarche, when the adrenal glands mature and manufacture the androgen hormone dehydroepiandrosterone (DHEA), occurring around ages 6 through 8 years in girls and about one year later in boys (Dorn & Biro, 2011). As DHEA begins to increase, sexual interests awaken, often manifested in teasing and roughhousing (Sharpe, 2003). Early adolescence is tile time when gonadarche occurs with reactivation of gonadotropin-releasing hormone and secretion of estradiol and testosterone, leading to development of the primary sex organs (testes, ovaries) and a variety of physical changes in boys and girls called secondary sex characteristics (e.g., breast and genital development). Toward the end of this substage, youth go through a predictable process of biological development called puberty. Puberty refers to a stage of biological maturation where a boy or girl becomes capable of reproduction and develops an adult-like body'.
The average age for puberty to begin for girls is between 10 and 11 years and for boys between 11 and 12 (Haffner. 2004), although normal pubertal changes may begin as early as age 8 for girls and 9 for boys. Early pubertal timing in girls is associatcd with psychosocial problems throughout adolescence (i.e., substance use, early sexual behavior; Mendle, Turkheimer, & Emery, 2007). and early maturers are also at risk for depression and having many sexual partners in young adulthood (Copeland et al., 2010). In contrast, early-developing boys seem to have few problems and are more likely to be popular, good in sports, and school leaders. Late-maturing boys actually have more problems than those who mature early.
For both boys and girls, the biological and physical changes of puberty lead to a flood of emotions, most noticeably a new interest in romantic relationships and sex. Around age 10, both sexes begin to have sexual thoughts and feelings and attractions to others (Herdt & McClintock, 2000). Sexual attraction coincides with rising androgen levels due to the maturation of the adrenal glands. Now children begin to purposefully masturbate for sexual pleasure, usually in private. Boys are more likely than girls to masturbate, either alone or with other boys (Hyde & Jaffe, 2000). Unlike the more casual genital touching or rubbing typical of earlier stages, preteens masturbate to experience arousal, orgasm, or ejaculation. Research shows that as many as three quarters of boys and about half of girls under the age of 15 masturbate (Haffner, 2004). There are also cultural differences: Masturbation is more common among White adolescents than among African American teens (King. 2009). A study of adults' childhood recollections found that over half of both men and women had masturbated to orgasm by age 12 (Ryan, 2000a). Women who said they started masturbating before puberty (defined as before menarche) had more positive attitudes about sex, more positive sexual experiences, and better sexual sell-esteem than women who did not report early-onset masturbation (Bancroft, Herbenick, & Reynolds, 2003; Smith, Rosenthal, & Reichler, 1996).
During this stage of development, children become more modest and may want increased privacy. It is not uncommon to see a sign posted on a child's door that says, "KEEP OUT!" Modesty prevails at this age, and children are shy about undressing, even in the presence of their same-sex parent. They may also be embarrassed about undressing in front of peers, because of a concern about being too developed or underdeveloped compared to their friends. For example, a boy who is concerned about the size of his penis or a girl who is embarrassed about her breast size may be reluctant to change in the locker room at school. With regard to their relationship with their parents, teens often become less physically demonstrative and may be embarrassed by physical affection from parents. As they age, children want more emotional freedom and space from parents. This emotional and physical distancing is believed to have biological roots in that children are preparing, ultimately, for a time when they ;viii no longer be living with their parents.
As tweens become aware of themselves as sexual beings and of their peers as potential partners, many start connecting romantically. Some start "going together" or "hanging with" a boyfriend or girlfriend sometime in middle school. In a national survey of youth ages 12-14, 39% of 12-year-olds reported being in a romantic relationship (Bruckner & Bearman, 2003). Their concrete thinking may mean they like someone one day but hate them the next. Romantic crushes tend to be of short duration and rather innocent in terms of sexual behavior (e.g., holding hands during a school movie, sitting next to each other on school bus, saying "hi" in the hallway). These (typically) short-lived relationships often involve experimenting with sexual behaviors like holding hands, hugging, and kissing, whereas touching each other's genitals under the clothes (often called "petting") is less likely (i.e., reported by 10% of 12-year-old girls and 13% of boys) (Bruckner & Bearman, 2003). Fewer tweens report having intercourse; only 7% of teens report having sex by age 13 (Eaton et al., 2008). Not all tweens are interested in dating (about 20% of youth said they did not have romantic attractions in Russell & Self, 2002), and not all preteenagers are interested in people of the opposite gender. In fact, it is common for preadolescents and adolescents to be attracted to people of the same sex; to develop crushes on a teacher, counselor, or coach of the same sex; and to have sexual experiences with a same-sex friend (Haffner, 2004). Most of these same-sex experiences are short lived and not predictive of a homosexual orientation. However, sexual orientation usually emerges during the mid- to late-teenage years, with most gays and lesbians having their first same-sex sexual experiences around the ages of 13-14 years (13.5 for males, 15.5 15r females; CDC, 2010).
Romantic relationships can provide many benefits for teens. Having a boyfriend or girlfriend makes teens more popular with their peers. Romantic partners provide acceptance, companionship, and emotional comfort to weather the storm of adolescence. Dating also helps teens explore their sexual identity and prepares them for adult romantic relationships. Thus, through romantic relationships teens gain intimacy, social status, and pleasure (Oft, Milstein, Ofner, & Halpern-Felsher, 2006).
The pubertal and social transitions of early adolescence may explain the increased likelihood of tweens perpetrating sexual harassment, also referred to a sexual bullying (SB; Fredland, 2008), seen as an early form of sexual harassment. According to Fredland (2008), examples of SB common to this age group include touching, grabbing, pinching in a sexual way; brushing up against someone in a sexual way on purpose; giving someone sexual pictures, messages, or notes; name calling such as slut, gay, or "lesbo"; writing sexual messages / graffiti in school restrooms; spreading sexual rumors; and forcing someone to do something sexual such as kissing or oral sex. A substantial number of youth, both boys and girls, are involved in SB with same-gender and cross-gender peers. McMaster, Connolly, Pepler, and Craig (2002) found that cross-gender sexual harassment at school increased in youths from grades 6-8, and that boys perpetrated and experienced more same-gender than cross-gender harassment, while the reverse was found for girls. The authors note that the greater cross-gender focus of girls' harassment may reflect their earlier onset of pubertal maturation, developing sexual interest in boys, and spending more time in mixed-gender peer groups. Early-maturing girls and gay and lesbian youths are common targets of SB (Perry & Pauletti, 2011). Although peer-to-peer sexual harassment is frequent as children enter adolescence, McMaster et al. noted that it is "by no means a necessary or healthy aspect of adolescence" (p. 104) and recommended that interventions to prevent its development be put in place prior to high school. As suggested by Fredland (2008), identifying inappropriate sexual behavior such as SB and intervening early may prevent deviant behavioral patterns (like dating violence) from developing.
Not only does SB occur at school, but it is also perpetrated using electronic technology (e.g., through email, in a chat room, via instant messaging, on a web site, or through digital messages or images sent to a cell phone; Kowalski & Limber, 2007). Males and females participate about equally in cyberbullying (Hinduja & Patchin, 2008). Sexting (e.g., a girl sends a nude picture of herself to a boy) and its consequences (e.g., the boy circulates the picture among his friends, the girl is humiliated, and in tragic cases commits suicide) are also growing problems (Wurtele, 2011). Whether online or offline, SB represents an emerging public health problem (David-Ferdon & Hertz, 2007).
As curiosity about sexual behavior increases, some children begin seeking out sexual content in media (television, movies, games, music, magazines, internet). Longitudinal studies have found that young adolescents' exposure to sexual content in the media is related to subsequent sexual behavior, including earlier intercourse and greater risk for pregnancy and sexually transmitted disease (see reviews by Brown & Bobkowski, 2011, and Stasburger, Jordan, & Donnerstein, 2010). The newer media (e.g., the internet, cell phones) are also important sexual socialization agents. About 20% of children between ages 10 and 17 who have a computer at home use the internet to get health or medical information (Brodie et al., 2000). Adolescents use the internet to ask questions about sexual topics, exchange information with peers about sexuality, and explore their emerging sexuality (Subrahmanyam, Greenfield, & Tynes, 2004; Suzuki & Calzo, 2004). Unfortunately, the internet can be a dangerous sex educator. Wolak, Mitchell, and Finkelhor (2007) found that 66% of children between 10 and 17 who used the internet were exposed to pornography in the past year. In a sample of middle-school youth, exposure to sexually explicit content predicted perpetration of sexual harassment (for males), more permissive sexual norms, having oral sex, and engaging in sexual intercourse while in high school (Brown & L'Engle, 2009). Given the importance of technology for children this age, it is not too alarming that they are using it to gain information about sexual material. However, parents should be concerned about the potential for internet sex addiction (Kuss & Griffiths, 2011) or when tweens view child pornography.
As sexual feelings and interests increase during this time, some youth (both boys and girls) try to satisfy their sexual curiosity by experimenting with younger children. Clinicians and researchers have become increasingly aware of young children (under the age of 12) who demonstrate sexual behavior problems (SBPs; Araji, 1997; Chaffin et al., 2008; Elkovitch et al., 2009). Sexual behaviors in children are considered problematic when they are either potentially harmful to themselves or others or are developmentally inappropriate or atypical. Furthermore, SBPs involve behaviors that "(a) occur at a frequency greater than would be developmentally expected; (b) interfere with children's development; (c) occur with coercion, intimidation, or force; (d) are associated with emotional distress; (e) occur between children of divergent ages or developmental abilities; or (f) repeatedly recur in secrecy after intervention by caregivers" (Chaffin, Letourneau, & Silovsky, 2002, p. 208). These youth have been referred to in the literature as "juvenile sex offenders," "children with sexual behavior problems," "sexually aggressive children," "children who molest," or even "mini-perps" (Chaffin & Bonner, 1998). Victims can include their siblings and cousins along with children in their care (e.g., while babysitting). In contrast to sexually abusive adults, intentions and motivations for their SBPs may or may not be related to sexual gratification or sexual stimulation. Instead, their sexual behaviors may be related to curiosity or anxiety, may be imitative or attention-seeking, a reaction to their own victimization or living in a sexually dysfunctional environment, or a way to meet intimacy needs and feel emotionally safer (Chaffin et al., 2008; Elkovitch et al., 2009; Johnson, 2009).
Implications for Sexuality Education/ Developmental Guidance
During this stage, it is important that parents and caretakers increase their communication on sexual topics with youth. Most important, children will need help understanding puberty and the myriad changes both boys and girls will experience. Children this age often want to know the answers to a variety of questions, including "What's a boner?" "What's sex?" "What's masturbation'?" "What's a period?" "What's a wet dream?" "What should I do when I get a hard on during class?" "What does 'gay' mean?" Parents need to prepare their sons and daughters for all the physical changes associated with pubescence, most importantly menarche (beginning menses) and erections during the day and at night (i.e., nocturnal emissions or "wet dreams"). With girls maturing earlier compared to decades ago (Dorn & Biro, 2011; Slyper, 2006), it becomes important to have these discussions early, between ages 8 and 10 or younger, especially for early-maturing girls. Discussions with children should emphasize that processes such as menstruation and nocturnal emissions are normal biological processes of development. Despite the embarrassment some parents may experience, they are still reported as the preferred source for information about sexuality by adolescents (Somers & Surmann, 2004). However, parents do not seem to be providing this much-needed education. More than half of adolescents report that they learned about pregnancy and birth control from television and movies, and more than half of adolescent girls state that they learned about sex from magazines (Brown & Witherspoon, 2002). Many boys said that, although they knew about ejaculation, no one spoke to them about it ahead of time or told them what physical changes would happen during puberty (Omar, McElderry, & Zakharia, 2003). Tweens who are prepared are more likely to react more positively to pubertal changes.
Parents also need to convey that growth and maturation rates differ from person to person and that different parts of their bodies will grow at different rates. Puberty affects children at different ages, and children may be comparing themselves to others and wondering when they will "catch up." They can be reassured that everyone will eventually change--and "get there." Parents can also help their tweens develop a healthy genital image by stating that everybody develops at a different rate and that their bodies are unique and beautiful (Berman, 2009).
Books and videos can be very helpful for both boys and girls. Parents can read them together or have books available for their children to read alone. It is also important that both genders be informed about the changes of puberty experienced by both boys and girls. As suggested by Haffner (2004), knowing what the other sex is experiencing may cut down on inappropriate teasing or insensitive comments. Appendix A includes resources for this age group. Since research on adolescence has shown that parents (primarily mothers) talk more to daughters than to sons about sexuality (Martin & Luke, 2010), both mothers and fathers may need assistance from counselors in how to handle such discussions with their children.
As tweens begin expressing sexual interest, adults can help them with this developmental challenge. This age is a prime time for caregivers to insert family values and religious or moral beliefs into discussions about intimate relationships, dating, and sexual activities. As children develop relationships with peers that are based on attraction, parents can use these "first love" experiences to share their values about healthy intimate relationships and also to continue emphasizing body ownership and respectful relationships. Tweens and teenagers with a healthy concept of body ownership are more likely to take responsibility for keeping themselves sate in many situations, for protecting their sexual and reproductive health, and for avoiding sexual behaviors that are harmful to themselves or others (Wurtele & Berkower, 2010).
A child who asks for permission to date presents the perfect opportunity for parents to talk about dating rights and responsibilities. This is an ideal time to promote healthy relationships and prevent patterns of dating violence that can last a lifetime (Wurtele, 2011). Setting limits on a child's dating is very important, especially for young girls, as early dating is more likely to lead to involvement in high-risk behaviors: drinking, doing drugs, having intercourse, and getting pregnant. Parents should be cautious about allowing their middle-school children to date, especially if their children are dating someone much older. Parents need to carefully monitor their young teens' dating and romantic activities and communicate more with their young teens about sex, love, and relationships. Topics of importance for tweens include making decisions in the context of relationships ("Do I really want to do these sexual things with this boy now?"), recognizing risky social situations and potential dangers of dating (i.e., sexual pressure, date rape, dating violence), and treating partners--whether sexual or romantic--with respect. Given that sexual harassment increases during the early adolescent years and is evidenced at school (in "hostile hallways"; AAUW, 1993), parents, teachers, and counselors can help adolescents establish appropriate ways of interacting with cross-gender peers and promote norms for nonharassing ways of relating to each other.
Given children's increasing use of electronic communications, parents need to set developmentally appropriate guidelines for use of the new technologies (computers, webcams, digital cameras, mobile phones); discuss appropriate and inappropriate uses of these devices; and make sure teens know that cyberbullying is harmful and, in some cases like sexting, illegal (Wurtele, 2011). Using examples of teens involved in such cases and the consequences of their behaviors can serve as a good starting point for such discussions. Parents and educators will want to discuss the sale use of the internet with boys and girls (since girls outnumber boys in electronic bullying; Kowalski & Limber, 2007) and how to obtain reliable sexual information from the internet (see Wurtcle & Kenny, 2010b, and Appendix A for resources). Caregivers and educators will also want to help children decode the powerful messages about sex in the media (including television, advertisements, videos, videogames, internet, music, movies). This can be accomplished by parents spending time with children as they view movies, listen to music, or browse the internet and by media literacy classes offered in schools (David-Ferdon & Hertz, 2007). School administrators and counselors should work to educate students, teachers, and staff about electronic bullying and sexual bullying and ensure that school policies related to bullying and harassment include electronic and face-to-face forms of sexual bullying (Kowalski & Limber, 2007).
Given that some children engage in sexual behaviors with other children while supervising them (whether a family member or someone else's child), caregivers are encouraged to establish ground rules for tweens wishing to baby-sit. Parents can review body-safety rules tweens must follow to keep themselves, as well as the children they supervise, sale. Caregivers can emphasize that sexual contact with children is abuse, not play; that it is a crime and harms children; and that children can never consent to sexual relations (Wurtele. 2011).
Discussing self-stimulation is another way of normalizing these budding sexual feelings. Berman (2009) recommended that around age 12, parents say to their tween, "As you start to get older, your hormones might cause you to have some sexual feelings. That's completely normal and it's happening for everyone else in your grade, too" (p. 50). She recommends that parents then talk to their children about how self-stimulation is a healthy way to experience sexual pleasure without engaging in any emotionally or physically harmful behaviors. It is also important to emphasize that all sexual thoughts, feelings, emotions, and fantasies are normal during this age, but tweens need to learn to control their sexual behaviors and not act on their sexual arousal when inappropriate.
Nine- to 12-year-olds are going through the most rapid period of physical, social, and emotional development since toddlerhood. Preadolescence and early adolescence are marked by considerable biological changes and great variability in sexual exploration and experience. However, the swell in sexual thoughts, feelings, and behaviors is fairly universal. Toward the latter part of this stage, many children will begin to form romantic attachments to others, engage in masturbation for pleasure, move toward emotional independence from their parents, and desire more privacy. As they spend increasingly more time outside of the home with friends and are influenced by peers and the media, caretakers will need to amplify their efforts at sexuality education and include such topics as adjusting to pubertal changes, handling peer pressure, sexual orientation, and sexual decision making in romantic relationships. Although some parents may feel uncomfortable with such topics, research has shown that parent-child closeness and communication at this stage are highly important in helping children successfully navigate puberty.
The purpose of this paper was to provide a framework for parents, teachers, and counselors to understand children's sexuality development. As seen in this review, the notion that young children are asexual is incorrect. Humans arc sexual beings from early infancy, and childhood is a time when children explore and discover their own sexuality, both alone and through interacting with others. As we have seen, sexual behaviors in children are quite common, occurring in 42-73% of children by the time they reach the age of 13 (Kellogg, 2010). Our review has drawn attention to the notion that sexuality is a developmental phenomenon, and like other developmental domains (e.g., cognitive, physical, psychosocial), is affected by the child's ecology. By emphasizing childhood sexuality as expected and normative, we add to the recent push for consideration of positive sexuality development and less focus on the pervasive "problematizing of sexuality in terms of risk" (Tolman & McClelland, 2011, p. 250) typical of childhood and adolescent sexuality research during the twentieth century (Moran, 2000). We also emphasize that parents and professionals working with children have numerous opportunities to provide sexual abuse prevention education within the context of nurturing children's sexuality development. Through these efforts, children can get a head start toward becoming sexually healthy and respectful adolescents and adults as well as becoming less vulnerable to being sexually exploited and exploiting others.
APPENDIX A: SEXUALITY EDUCATION RESOURCES
Blank, J. (1993). A kid's first book about sex. San Francisco, CA: Down There Press.
Brooks, R., & Perl, S. (1983). So that's how I was born. New York: Simon & Schuster Books for Young Readers.
Brown, L. K., & Brown, M. (2000). What's the big secret? Talking about sex with girls and boys. New York: Little, Brown.
Cole, J. (1994). How you were born. New York: Harper Collins.
Curtis, J. L. (1996). Tell me again about the night I was born. New York: Harper Collins.
Eyre, L., & Eyre, R. (1999). How to talk to your child about sex: It's best to start early, but it's never too late--A step-by-step guide for parents. New York: Golden Guides from St. Martin's Press.
Freitas, C. (2010). The birds and the bees with ease. Healthy Chats LLC. (also available in Spanish)
Girard, L. W. (1992). You were born on your very first birthday. Niles, IL: Whitman.
Gordon, S., & Gordon, J. (1992). Did the sun shine before you were born ? Amherst, NY: Prometheus Books.
Harris, R. (2004). It's so amazing!: A book about eggs, sperm, birth, babies, and families. Somerville, MA: Candlewick Press.
Harris, R. (2006). It's not the stork: A book about girls, boys, babies, bodies, families and friends. Somerville, MA: Candlewick Press.
Mayle, P. (2000). Where did I come from? The facts of life without any nonsense and with illustrations. New York: Kensington.
Meredith, S. (1999). Where do babies come from? London: Usborne.
Nilsson, L., & Swanberg, K. L. (1996). How was I born?: A child's journey through the miracle of birth. New York: Bantam Dell.
Richardson, J., & Schuster, A. (2003). Everything you never wanted your kids to know about sex, but were afraid they'd ask: The secrets to surviving your child's sexual development from birth m the teens. New York: Crown.
Saltz, G. (2005). Amazing you! Getting smart about your private parts. New York: Dutton Children's Books.
Schoen, M. (2008). Bellybuttons are navels. No location: BookSurge.
Stinson, K. (2006). The bare-naked book. Vancouver, BC, Canada: Annick Press.
Ziefert, H. (1990). Getting ready for new baby. New York: Harper & Row.
American Medical Association (2006). Boy's guide to becoming a teen. San Francisco: Jossey-Bass.
American Medical Association (2006). Girl's guide to becoming a teen. San Francisco: Jossey-Bass.
Annunziata, J., & Nemiroff, M. (2003). Sex & babies: First facts. Washington, DC: Imagination Press.
Bailey, J. (2004). Sex, puberty and all that stuff: A guide to growing up. London: Franklin Watts.
Bell, R. (1998). Changing bodies, changing lives: A book for teens on sex and relationships. New York: TimesBooks.
Blackstone, M. & Guest, E. H. (2000). Girl stuff: A survival guide to growing up. San Diego: Gulliver Books.
Bradley, M. J. (2004). Yes, your parents are crazy! A teen survival guide. Gig Harbor, WA: Harbor Press.
Cole, J. (1988). Asking about sex and growing up: A question and answer book for boys and girls. New York: HarperCollins.
Columbia University's Health Education Program. (1998). The "Go Ask Alice '" book of answers: A guide to good physical, sexual, and emotional health. New York: Holt Paperbacks.
Dunham, K. (2007). The boy's body book: Everything you need to know for growing up YOU. Kennebunkport, ME: Applesauce Press.
Dunham, K. (2008). The girl's body book: Everything you need to know for growing up YOU. Kennebunkport, ME: Applesauce Press.
Gitchel, S., & Foster, L. (2005). Let's talk about S-E-X. Minnetonka, MN: Book Peddlers.
Gravelle, K. (1998). What's going on down there? Answers m questions boys find hard m ask. New York: Walker.
Gravelle, K., & Gravelle, J. (1996). The period book. New York: Walker.
Gurian, M. (1999). From boys to men: All about adolescence and you. New York: Price Stern Sloan.
Harris, R. (2009). It's perfectly normal: Changing bodies, growing up, sex, and sexual health. Somerville, MA: Candlewick Press.
Jukes, M. (2002). The guy's book: An owner's manual. New York: Crown.
Loulan, J., & Worthen, B. (2001). Period. Minnetonka, MN: Book Peddlers.
Madaras, L., & Madaras, A. (2007). The "What's happening to my body?" book for boys. New York: Newmarket Press.
Madaras, L., & Madaras, A. (2007). The "What's happening to my body?" book for girls. New York: Newmarket Press.
Mayle, P. (2000). What's happening to me? An illustrated guide to puberty. New York: Kensington.
Saltz, G. (2007). Changing you: A guide to body changes and sexuality. New York: Dutton Juvenile.
Schaefer, V. (1998). The care & keeping of you: The body book for girls. Middleton, WI: Pleasant Company.
Yeager, S. (2002). What's with my body? The girls 'book of answers to growing up, looking good, and feeling great. New York: Prima Lifestyles.
Books for Parents:
Bell, A. R., & Zeigler-Wildflower, L. (1983). Talking with your teenager. A book for parents. New York: Random House Press.
Berman, L. (2009). Talking to your kids about sex: Turning "the talk" into a conversation for life. New York: Dorling Kindersley Limited.
Bernstein, A. C. (1994). Flight of the stork: What children think (and when) about sex and .family building. Indianapolis, IN: Perspectives Press.
Bradley, M. J. (2003). Yes, your teen is crazy! Loving your kid without losing your mind. Gig Harbor, WA: Harbor Press.
Calderone, M.S. (1983). Talking with your children about sex: Questions and answers for children from birth to puberty. New York: Ballantine.
Calderone, M., & Johnson, E. (1981). Family book about sexuality. New York: Harper and Row.
Cavanagh, T. J. (1999). Understanding children's sexual behaviors: What's natural and healthy. Oakland, CA: New Harbinger.
Family Health Council, Inc. (2000). Family Connections: A guidebook for parents and children. Pittsburgh, PA: Author.
Flowers, J. V. (1982). Raising your child to be a sexually healthy adult. Englewood Cliffs, NJ: Prentice-Hall.
Goldman, R. (1988). Show me yours: Understanding children's sexuality. New York: Penguin Books.
Haffner, D. W. (2002). Beyond the big talk: Every parent's guide to raising sexually healthy teens from middle school to high school and beyond. New York: Newmarket Press.
Haffner, D. W. (2008). From diapers to dating: A parent's guide to raising sexually healthy children--from infancy to middle school. New York: Newmarket Press.
Hickling, M. (2005). The new speaking of sex: What your children need to know and when they need to know it. Kelowna, BC, Canada: Wood Lake.
Howard, M. (1988). How to help your teenager postpone sexual involvement. New York: Continuum.
Leight, L. (1988). Raising sexually healthy children: A loving guide for parents, teachers, and caregivers. New York: Rawson Associates.
Lewis, H. R. (1983). Sex education begins at home: How to raise sexually healthy children. E. Norwalk, CT: Appleton-Century-Crofts.
Maxwell, S. (2008). The talk: What your kids need to hear from you about sex. A breakthrough guide to raising healthy kids in an oversexualized, online, in-your-face world. New York: Penguin.
Palmer, P. (1989). Teen esteem. Toronto: Impact.
Pipher, M. (1994). Reviving Ophelia: Saving the selves of adolescent girls. New York: Riverhead Books.
Riera, M. (2003). Staying connected to your teenager: How m keep them talking to you and how to hear what they're really saying. Cambridge, MA: Perseus.
Roffman, D. M. (2001). Sex and sensibility: The thinking parent's guide to talking sense about sex. New York: Perseus.
Roffman, D. M. (2002). But how'd I get in there in the first place? Talking to your young child about sex. New York: Perseus.
Schwartz, P., & Cappello, D. (2000). Ten talks parents must have with their children about sex and character. New York: Hyperion Press.
Sutton, R. (1997). Hearing us out: Voices from the gay and lesbian community. Toronto: Little Brown.
Wilson, P. M. (1991). When sex is the subject: Attitudes and answers for young children. Lawrenceville, GA: Network.
Wolf, A. E. (2002). Get out of my life, but first could you drive me and Cheryl to the mall? A parent's guide to the new teenager. New York: Farrar, Straus and Giroux.
Wurtele, S. K., & Berkower, F. (2010). Off limits: A parent's guide to keeping kids safe from sexual abuse. Brandon, VT: Safer Society Press.
WEBSITES for Young People
Birds and Bees--www.birdsandbees.org
Go Ask Alice!--www.goaskalice.columbia.edu
I Wanna Know--www.iwannaknow.org
WEBSITES for Parents
www.advocatesforyouth.org (Advocates for Youth has a Parents Sex Education Center)
www.cfoc.org (Campaign For Our Children website has information for both parents and teens)
www.drspock.com (Dr. Spock's Web site)
www.familiesaretalking.org & www.lafamiliahabla.org (The Sexuality Information and Education Council of the United States has developed this website for parents on sexuality education in the home.)
www.plannedparenthood.org (Planned Parenthood Federation of America's Web site includes resources for parents.)
www.talkingwithkids.org (The Kaiser Family Foundation sponsors this site.)
www.aap.org (American Academy of Pediatrics)
www.siecus.org (Sexuality Information & Education Council of the U.S. This Web site offers a section for parents and caregivers.)
http://thriveonline.oxygen.com/sex/experts/sex ed mom/index.html (Sex Ed Mom. This Web site is "a parent's guide to the birds and the bees.")
www.goaskalice.columbia.edu (Go Ask Alice! This Web site is maintained by Columbia University's Health Education Program. It uses a question-and-answer format to provide information.)
Videos about Childhood Sexuality
Committee for Children's What do I say now? DVD www.cfchildren. org.
Committee for Children's Yes You Can Say No. DVD www.cfchildren. org.
Communication about Sexual Health Begins at Birth. These parents and young people tell how they discuss sexual health. Experts offer insight and skills to help families start and continue these conversations. Includes discussion guides. Recommended for parents and other caregivers.
Program #1 For parents of young children. Addresses setting limits, labeling body parts, how babies are made, self-touch, appropriate/inappropriate touch and more.
Program #2 For parents of preadolescents and adolescents. Addresses sharing values, keeping communication open, postponing sexual intercourse, avoiding absolutes, building strong relationships and more. Each program is 20 minutes.
The Growing Up Series. National Film Board of Canada, Ottawa, Canada, 1989. A series of three videos designed for parents to watch with their preadolescent children. It serves as an introduction to sexuality education, http://www.tsbvi.edu/Education/sexuality-education-parent.htm
Raising Healthy Kids[TM]: Families Talk about Sexual Health-DVD www.advocatesforyouth.org, order at www.wordscanwork.com.
Where Do Babies Come From? Starring Ruth Hummel. Concordia Publishing House.
American Academy of Pediatrics. (AAP). (2011). Talking with your young child about sex. Healthy Children. Retrieved from www. healthychildren.org
American Association of University Women. (AAUW). (1993). Hostile hallways: The AAUW survey on sexual harassment in America's schools. Washington, DC: American Association of University Women Educational Foundation.
Araji, S. K. (1997). Sexually aggressive children: Coming to understand them. Thousand Oaks, CA: Sage.
Bahali, K., Akcan, R., Tahiroglu, A. Y., & Avci, A. A. (2010). Child sexual abuse: Seven years in practice. Journal of Forensic Sciences, 55(3), 633-636.
Bancroft, J., Herbenick, D. L., & Reynolds, M. A. (2003). Masturbation as a marker of sexual development. In J. Bancroft (Ed.), Childhood sexual development (pp. 156-185). Bloomington: Indiana University Press.
Berman, L. (2009). Talking to your kids about sex: Turning "the talk" into a conversation for life. New York: Dorling Kindersley.
Brodie, M., Flournoy, R. E., Altman, D. E., Blendon, R. J., Benson, J. M., & Rosenbaum, M. D. (2000). Health information, the Internet, and the digital divide. Health Affairs. 19(6), 255-265.
Brown, J. D., & Bobkowski, P. S. (2011). Older and newer media: Patterns of use and effects on adolescents' health and well-being. Journal of Research on Adolescence, 21(I), 95-113.
Brown, J. D., & L'Engle, K. L. (2009). X-rated: Sexual attitudes and behaviors associated with U.S. early adolescents' exposure to sexually explicit media. Communications Research, 36(1), 129-151.
Brown, J. D., & Witherspoon, E. M. (2002). The mass media and American adolescents' health. Journal of Adolescent Health, 31, 153-170.
Bruckner, H., & Bearman, P. (2003). Dating behavior and sexual activity of young adolescents: Analyses of the National Longitudinal Study of Adolescent Health. In B. Albert, S. Brown, & C. M. Flanigan, (Eds.), 14 and younger: The sexual behavior of young adolescents (pp. 31-56). Washington, DC: National Campaign to Prevent Teen Pregnancy.
Bussey, K., & Bandura, A. (1984). Influence of gender constancy and social power on sex-linked modeling. Journal of Personality and Social Psychology, 47, 1292-1302.
Centers for Disease Control and Prevention (CDC). (2010). A public health approach for advancing sexual health in the United States. Meeting report of an external consultation. Atlanta, GA: Author.
Chaffin, M., Berliner, L., Block, R., Cavanagh-Johnson, T., Friedrich, W. N., Louis, D. G., et al. (2008). Report of the ATSA Task Force on children with SBP. Child Maltreatment, 13, 199-218.
Chaffin, M., & Bonner, B. (1998). "Don't shoot, we're your children": Have we gone too far in our response to adolescent sexual abusers and children with sexual behavior problems? Child Maltreatment, 3(4), 314-316.
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Dr. Wurtele is a professor in the Psychology Department at the University of Colorado at Colorado Springs. Dr. Kenny is a professor in the College of Education at Florida International University.
TABLE 1 Infancy and Toddlerhood (Birth to 2 years) Common Behaviors Concerning Educational Behaviors/Signs Implications * Explores own body, * Irritation/ * Provide ample including genitals inflammation of warmth, affection, penis/vulva touching, and love. * Spontaneous, reflexive sexual * Physical trauma to * Teach correct response (erection, genitals, sexually names of body parts, lubrication) transmitted including genitals. infections (STIs) * Enjoys touch (signs of possible * Help child (hugs, cuddling) sexual abuse) understand differences between * Enjoys nudity * Child is resistant boys and girls. (likes to take off or fearful of touch clothes and walk from caregivers * Encourage around naked) androgynous roles/ activities while * Since learning is also helping primarily through children understand touching at this their own gender. age, may want to touch others' * Allow child to private parts explore own body; usually after age * Self-stimulation 3, a child is old as a form of self- enough to understand soothing and that even though it self-comforting feels good, self- touching should be * If toilet training done in private (do is beginning, may not shame or punish show an interest in child for sexual others' bathroom exploration or behavior stimulation). * Stands too close to people TABLE 2 Guidelines for siblings engaging in certain family practices, given in years * Same- Mixed- gender gender Activity siblings siblings Bathing 5 4 Showering 6 4.5 Sleeping in same room 14 6 Sleeping in same bed 8 5 Changing clothes (including underwear) 10 5 Using toilet together 7 5 * Maximum acceptable ages. Source: Adapted from "Sibling Family Practices: Guidelines for Healthy Boundaries," by T. Johnson, B. Huang, and P. Simpson, 2009, Journal of Child Sexual Abuse, 18, pp. 339-354. TABLE 3 Early Childhood (3-6 years) Common Behaviors Concerning Educational Behaviors/Signs Implications * Plays consensual * Plays "sex" games * Teach children "sex" games with after being told not rules about keeping similar-age peers, to certain parts of usually motivated by the body private and curiosity about * Forces or coerces keeping their physical differences peers to take off clothes on while between boys and clothes and play playing. girls (involves "sex" games showing or * Help children touching private * Any penetration of understand physical parts) others' differences between genitals/rectum boys and girls. * Understanding of with fingers or genitals limited to objects * Teach rule to keep elimination private parts covered functions; most are * Oral contact with up when in unaware of sexual another child's public. functions genitals * Respect other * Exhibitionism * Asking to be people's privacy (e.g., enjoys touched in his or (teach child to nudity, shows her genital area observe closed doors genitals to an adult and knock before or other children, * Engages in sexual entering bathrooms not embarrassed activities with and bedrooms). about nakedness) animals * Let children know * Voyeurism (e.g., * Shows genital that it may feel tries to view areas to adults good to touch parts peer/adult nudity; of body, including watches * Persistent nudity your penis or vulva, opposite-gender or sexual behavior but that parent urinate; is in public after self-touching of interested in seeing having been given genitals is others naked) privacy guidelines something they should do in private * Touching/rubbing * Touches an adult's ("It's OK in your of genitals in genitals room, but not in the public/private grocery store"). * Excessive * May put something masturbation, * Discuss concept of in own genitals or touching, rubbing boundaries and rectum one time for of genitals (causes personal space. curiosity or trauma or irritation exploration to genitals) * Teach that they are in charge of or * Touching * Continues to in control of their genitals/breasts of touch/rub genitals own bodies. "Your parents/siblings/ in public after body belongs to you" peers being told not to or "You are the boss of your body" * Physical intimacy * Masturbates with (Wurtele, 2007). (cuddling and objects Teach body-safety romping) rules about not * Leaves fun touching anyone * Stands/sits close activities to else's private parts to familiar persons masturbate or letting anyone else (except * Awareness of * Makes groaning or parents/doctors) differences between moaning sounds while touch their private boys and girls; able masturbating or parts ("No one has to make distinction engages in thrusting the right to touch based on genital motions while your private differences masturbating parts"). * May use slang * Uses coercion, * Teach children terms for genital force to put objects difference between body parts or fingers in vagina OK and not OK or rectum of self or touches (avoid use * Asks about other person of good and bad genitals, touch). reproduction * Regularly hugs adults he or she * Provide * Wants privacy in does not know well age-appropriate sex bathroom or changing education. clothes * Sexual play with dolls * Teach accurate * Modesty names for body parts * Provocative behavior with adults * Teach rules about * Interested in personal safety socializing with * Advanced sexual while at home and similar- aged knowledge out and about. children * Seems obsessed * Explain that these * Claims to have with sex rules apply to "boyfriend" and friends and "girlfriend" * Excessive relatives as well as questions or talk strangers. * Plays house, acts about sexuality out roles of mommy * Begin to teach and daddy * Becomes upset assertiveness (aggressive, skills. * Enjoys being a fearful) when denied "boy" or "girl" privacy * Practice "what if" role plays (What if * By end of this * Consistently someone tried to period, majority prefers to play with touch you?) empha- have well-developed much younger sizing the need to sense of gender children tell about unsafe identity, but not touch requests and all children * Fearful of or that unsafe or "not understand that they aggressive toward OK" touching is will always be that opposite-gender never the child's gender people fault. * Attempts advanced * Stop cobathing and sexual behaviors cosleeping (sib with peers (e.g., lings and tongue kissing) parent-child). If siblings want to * Attempts or continue joint simulates bathing, remind intercourse children not to touch (humping) or each others' oral-genital contact genitals. * Believes she or he * Encourage is the opposite self-care (during gender or he or she bathing and after wants to be the using the toilet). opposite gender Use these moments to reinforce the * Drawings, games, concept that no one or fantasies that else is allowed to involve touch his or her inappropriate sexual genitals. activities or depict advanced sexual knowledge TABLE 4 Early Elementary School Children (6-9 years) Normal Behaviors Concerning Educational Behaviors/Signs Implications * Asks about * Child has advanced * Provide more genitals, breasts, sexual knowledge, detailed information inter- course, gestures, language, about sexual issues babies and activities (e.g., anatomy and reproduction), even * May seek out books * Continuously uses if a child does not or websites on sexual or obscene ask for it. sexual matters language even after told not to and * Emphasize that * Uses "dirty" words parents/relatives do sexual activities for sexual behavior; not use these words (including oral sex, tells sexual or fondling, inter obscene jokes * Coerces/forces/ course) are for bribes much younger adults only, not * Limited children to play children. understanding of "sex games" adult sexual * Set rules in your behavior * Is preoccupied home for what words with sexual play, are acceptable and * Plays "sex games" especially with unacceptable to say, with same-aged much younger or especially in children involving older children public. Explain that touching and looking others may be (e.g., truth or * Engages in or offended by hearing dare) attempts advanced these words. Check sexual activities your child's knowledge * Compares genitals (oral sex, digital about what an with siblings and penetration, unacceptable word peers (close in age) intercourse) means. Sometimes they stop using * Self-stimulation * Forces child to obscenities when of genitals; shows take clothes off and they know what they others his/her touches/inserts mean. genitals in private something in child's location genitals * If a child uses obscenities when * Plays house, * Demands to angry or frustrated, simulating see/touch others' teach more mother/father roles genitals, breasts, appropriate ways of or buttocks expressing emotions. * May put something in own * Excessive * Explain that genitals/rectum touching/rubbing of touching or playing genitals in public; with private parts * Takes advantage of shows genitals in can feel nice, but opportunity to look public it's something at others' genitals, people only do in buttocks, breasts * Preoccupation with private. masturbation * Single or * Explain concepts infrequent * Masturbation which of heterosexuality, occurrences of includes vaginal or homosexuality, and peeping/exposing anal penetration bisexuality. * Affectionate * Imitating * Treat classmates behavior with peers intercourse (same- and opposite (e.g., kissing, sex) with respect. flirting) * French (tongue) Adults should inter kissing vene when children * Cuddles and romps engage in sexually with familiar * Uses disrespectful adults/children coercion/force to behaviors, stressing insert some- thing that these behaviors * Becomes aware of into vagina/rectum or words may hurt or different forms of of self, others, upset others and are sexual orientation dolls, or animals. not allowed. Causes harm to * Child's sense of own/others' * Continue teaching gender constancy genitals/rectum. about privacy. Set (will always be male family rules about or female) is * Sneaks peeks at respecting each complete others while naked other's rights to even after privacy, and teach * Teases, calls reprimanded that children's names, makes sexual private parts are comments to or about * Wants to watch private. opposite-sex peers nudity on television * Repeated or chronic peeping/exposing * Exposes others' genitals (e.g., pulling down pants or exposing breasts) * Simulates intercourse with dolls, peers, animals (i.e., humping) * Harasses/uses discriminatory labels/terms TABLE 5 Early Adolescence (9-12 years) Normal Concerning Educational Behaviors Behaviors/Signs Implications * Shows sexual * Engages in * Provide interest in peers of adult-type sexual broad-based sexual similar age activities with health education. (feelings of sexual younger children attraction) * Provide * Forces a younger information about * Begins dating child to have oral, sexual issues (e.g., (hanging out, going vaginal, or anal sex reproduction, with) usually in pregnancy), even if groups * Preoccupied with a child does not ask sex and for it. * Start of sexual relationships attraction/interest * Discuss dating in peers * Frequents sexually (relationship) explicit websites rights and * Puberty begins or responsibilities. continues, body * Shows pornography changes can result to younger children * Review body-safety in anxiety and con- rules when inter fusion, needs * Difficulty acting with younger reassurance that adjusting to sexual children. changes are normal orientation * Respect child's * May have fantasies * Masturbation desire for privacy. about ideal partner; interferes with likely to be a academic or social * Help tweens celebrity life develop decision-making, * Some youth begin * Simulates communication, and to engage in kissing intercourse with assertiveness and fondling or dolls, peers, skills. other affectionate animals (i.e., behavior with peers humping) * Help tweens (e.g., flirting) recognize and * Manually respond to peer * Asks questions stimulates or has pressure. about sex oral or genital contact with animals * Discuss family * Displays more values about dating advanced knowledge * Exhibits sexual and love and the about sexuality bullying, whether in role of sexuality in (draws sexual parts, real life or online relationships. uses sexual words, talks about sexual * Touches adults in * Keep the acts, looks at nude a manner more like conversation going. photos) adult-adult sexual contact, offers him- * Develop media * Seeks out sexual or herself as a literacy skills to information from sexual object, under stand, media and internet solicits sexual interpret, and (wants to see touch from adults evaluate sexual photos of naked or messages and partially naked * Sexualizes imagery. people) nonsexual things or sees people as * Discuss * Listens to music, sexual objects appropriate and watches movies with inappropriate uses sexual themes * Uses coercion, of electronic force, bribery, devices before * Desires more manipulation, or purchasing new privacy, may want threats to engage technologies. bedroom door another child in locked sexual behavior * Emphasize safe connections and * Awareness of own * Exposes genitals boundaries whether and others' sexual and/or masturbates in person or online. orientation in public * Discuss internet * Shows secondary safety and teach sex characteristics kids to be (signs of puberty) respectful of others online and not to * Menstruation and engage in "sex talk" nocturnal emissions online or electronically bully * Masturbates (in others. private) for pleasure and orgasm * Talk about how to recognize and avoid * Most early sexual risky social experiences are with situations. the opposite sex but may engage in * Provide same-sex activity information about (does not indicate basic physical homosexuality) changes of puberty. * Provide tweens with age-appropriate sexuality books. * Discuss family values about pornography (e.g., the way women and children are viewed as sexual objects, only to be used for sexual satisfaction; the association of sex with violence).