Sexuality

1. Normal Sexual Development
   1. Key Points of Normal Sexual Development
   2. Management of Normal Sexual Development
2. Sexual Behaviors
   1. Key Points of Sexual Behaviors
   2. Definitions of Sexual Behaviors
      1. Variations
      2. Problems
      3. Disorders
   3. Clinical Guides for Sexual Behaviors
   4. Differential Diagnosis of Sexual Behaviors
   5. Management of Sexual Behaviors
   6. Comorbid Conditions of Sexual Behaviors
3. Sexual Identity
   1. Key Points of Sexual Identity
   2. Definitions
      1. Variations
      2. Problems
      3. Disorders
   3. Differential Diagnosis and Co-Morbid Conditions of Sexual Identity
   4. Management of Sexual Identity
4. Resources for Parents
5. Tools
6. References

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• 2 years: Volbert (2000) found that 75% of 2-year olds could label both male and female genetalia.
  Volbert (2000) found that 75% of 2-year olds could label both male and female genetalia.
• intrauterine growth: Volbert (2000) found that 43% of 4 year olds mentioned intrauterine growth when asked about pregnancy, but less than 3% could explain it.
  Volbert (2000) found that 43% of 4 year olds mentioned intrauterine growth when asked about pregnancy, but less than 3% could explain it.
• May express that sexual stereotyping is wrong: When presented with a vignette, 72% of girls and 52% of boys said it was not right to stereotype based on sex.
  When presented with a vignette, 72% of girls and 52% of boys said it was not right to stereotype based on sex.
• 6 years: 1)Volbert (2000) found that 50% of 6 year olds explained that birth occurs either vaginally or through cesarean section. Only 17% explained that both ways were possible. 2) Fewer than 17% understand sexual function of genitalia.
  1)Volbert (2000) found that 50% of 6 year olds explained that birth occurs either vaginally or through cesarean section. Only 17% explained that both ways were possible. 2) Fewer than 17% understand sexual function of genitalia.
• First intercourse usually occurs during the teenage years in the United States: The CDC's Youth Risk Behavior Surveys (1998,2000) find that the rate of sexual activity among 9-12 grade girls has consistently hovered around 50% for much of the last 2 decades. For boys, the current rate is also about 50%, while during the early 1990s it was slightly higher.
  The CDC's Youth Risk Behavior Surveys (1998,2000) find that the rate of sexual activity among 9-12 grade girls has consistently hovered around 50% for much of the last 2 decades. For boys, the current rate is also about 50%, while during the early 1990s it was slightly higher.
• Just over half of teens use barrier contraception: In the Youth Risk Behavior Surveillance study conducted by the CDC (1998), 57% of sexually active teens (about one-third of all surveyed) used a barrier contraceptive the last time they had intercourse in the past 3 months.
  In the Youth Risk Behavior Surveillance study conducted by the CDC (1998), 57% of sexually active teens (about one-third of all surveyed) used a barrier contraceptive the last time they had intercourse in the past 3 months.
• Just under 1 million teenagers become pregnant each year: About two-thirds of these pregnancies are to 18 &19 year olds and one-third are to girls younger than 17. About 51% of these teenage pregnancies result in a live birth.
  About two-thirds of these pregnancies are to 18 &19 year olds and one-third are to girls younger than 17. About 51% of these teenage pregnancies result in a live birth.
• An estimated 2.5% of adolescents identify as gay, lesbian or bi-sexual: Trigger questions : 1) "Have you ever had a romantic relationship with a boy or a girl?" or 2) "When you think of people to whom you are sexually attracted, are they men, women, both, neither, or are you not sure yet?" 3) Assess questioning or homosexual youth for suicidality. Recent research finds gay, lesbian or bi-sexual youth are 3.4 times as likely to report a suicide attempt as heterosexual youth.
  Trigger questions : 1) "Have you ever had a romantic relationship with a boy or a girl?" or 2) "When you think of people to whom you are sexually attracted, are they men, women, both, neither, or are you not sure yet?" 3) Assess questioning or homosexual youth for suicidality. Recent research finds gay, lesbian or bi-sexual youth are 3.4 times as likely to report a suicide attempt as heterosexual youth.
• Openly discuss sexuality: Use correct names for anatomical parts. Respect and be aware of family beliefs and values surrounding sexuality. This sets the stage for more in-depth discuss during the teenage years.
  Use correct names for anatomical parts. Respect and be aware of family beliefs and values surrounding sexuality. This sets the stage for more in-depth discuss during the teenage years.
• masturbation in early childhood: Masturbation during the toddler years is normal, but may be embarrassing for parents to talk about. Children can show arousal as early as the prenatal period, or during sleep, diapering, bathing, or dressing. Most children will learn how to create arousal in themselves by 12 months. After age 3 most girls become more private about it , boys later. Children who view adult sexuality either in person or on television or videos may be aroused by it or copy it. Help parents to protect children from this confusing stimulation. Help parents to manage this issue successfully by not over-reacting to toddler masturbation.
  Masturbation during the toddler years is normal, but may be embarrassing for parents to talk about. Children can show arousal as early as the prenatal period, or during sleep, diapering, bathing, or dressing. Most children will learn how to create arousal in themselves by 12 months. After age 3 most girls become more private about it , boys later. Children who view adult sexuality either in person or on television or videos may be aroused by it or copy it. Help parents to protect children from this confusing stimulation. Help parents to manage this issue successfully by not over-reacting to toddler masturbation.
• problem: Children who are under stress, anxious by nature, or very impulsive (e.g. Attention Deficit Disorder), or who don't understand social rules, may masturbate openly at older ages. These situations usually deserve treatment for their own sake.
  Children who are under stress, anxious by nature, or very impulsive (e.g. Attention Deficit Disorder), or who don't understand social rules, may masturbate openly at older ages. These situations usually deserve treatment for their own sake.
• start discussions about sexuality well in advance of puberty and the onset of sexual activity: Use upcoming developmental milestones as springboard for discussion (i.e., menstruation for girls or nocturnal emissions for boys).
  Use upcoming developmental milestones as springboard for discussion (i.e., menstruation for girls or nocturnal emissions for boys).
• Advise parents of risk factors for early, coercive or unintended sexual activity.: Early puberty, sexual or physical abuse, antisocial or delinquent behavior, learning problems, poor academic performance, alcohol or drug use. Refer for assessment or therapy as indicated.
  Early puberty, sexual or physical abuse, antisocial or delinquent behavior, learning problems, poor academic performance, alcohol or drug use. Refer for assessment or therapy as indicated.
• sexual activity and discussing STDs during regular visits: Respect family beliefs and values. Millstein et al (1996) found that less than 50% of adolescents were asked about their sexual activity during regular visits with their primary care doctors. Even fewer were asked about contraceptive use or STDs
  Respect family beliefs and values. Millstein et al (1996) found that less than 50% of adolescents were asked about their sexual activity during regular visits with their primary care doctors. Even fewer were asked about contraceptive use or STDs
• Encourage parents to discuss sexual activity with their adolescents: Sometimes feelings of inadequacy prevent parents from teaching their children about sex. Only 45% of mothers had correct information concerning the time of the month when pregnancy was most likely to occur. Parents also may worry that their children don't want to talk about sex with them. However, research shows that 50% of boys and 63% of girls want to talk to their parents about sex.
  Sometimes feelings of inadequacy prevent parents from teaching their children about sex. Only 45% of mothers had correct information concerning the time of the month when pregnancy was most likely to occur. Parents also may worry that their children don't want to talk about sex with them. However, research shows that 50% of boys and 63% of girls want to talk to their parents about sex.
• Give questioning teens accurate and up-to-date information regarding sexual orientation in a nonjudgmental way.: There are many steps health providers can take to ensure a comfortable and confidential office visit for questioning and gay youth. 1) Verbally assure confidentiality for all patients, especially teenagers. 2) Establish a strict no tolerance policy on inappropriate comments and jokes by office staff. 3) Use gender neutral language. 4) Visibly place information on support groups, organizations and events related to non-heterosexual youth and their families in the form of brochures or posters in the office setting. 5) Health care providers who feel they cannot provide non-judgmental care and counseling to homosexual or questioning youth should make a referral to a colleague who can
  There are many steps health providers can take to ensure a comfortable and confidential office visit for questioning and gay youth. 1) Verbally assure confidentiality for all patients, especially teenagers. 2) Establish a strict no tolerance policy on inappropriate comments and jokes by office staff. 3) Use gender neutral language. 4) Visibly place information on support groups, organizations and events related to non-heterosexual youth and their families in the form of brochures or posters in the office setting. 5) Health care providers who feel they cannot provide non-judgmental care and counseling to homosexual or questioning youth should make a referral to a colleague who can
• Youth who self-identify as homosexual may be at increased for suicide: Homosexual teens were 3.4 times as likely to report a suicide attempt as heterosexual teens in a recent study.
  Homosexual teens were 3.4 times as likely to report a suicide attempt as heterosexual teens in a recent study.
• In children sexual behaviors may include: difficulty recognizing personal boundaries, exhibitionism, gender role behavior, self-stimulation, sexual anxiety, sexual interest, sexual intrusiveness, inappropriate sexual knowledge, and voyeuristic behavior: In a normative sample of 1114 children aged 2-12 years, Friedrich et al (1998) found that overall, these behaviors peak around age 5 for both boys and girls and then follow a precipitous drop-off.
  In a normative sample of 1114 children aged 2-12 years, Friedrich et al (1998) found that overall, these behaviors peak around age 5 for both boys and girls and then follow a precipitous drop-off.
• Display of any of these behaviors does not necessarily indicate a problem.: However, behaviors such as oral-genital contact, asking others to do sex acts and simulating intercourse were all rare. Children who display these behaviors should be evaluated further.
  However, behaviors such as oral-genital contact, asking others to do sex acts and simulating intercourse were all rare. Children who display these behaviors should be evaluated further.
• Differentiating sex play from sexual abuse: The following questions help differentiate sex play from sexual abuse. "1. Is it consistent with the developmental level of participants? 2. Is it consensual or coercive? 3. What is the motivation of the participants? 4. Is some outside influence involved? 5. What is the age difference between the participants? And 6. What is the response of the child to the episode? Normal sexual activity during childhood typically involves consenting, developmentally appropriate activities that are mutually motivated by curiosity and pleasure . . ."(p. 209).
  The following questions help differentiate sex play from sexual abuse. "1. Is it consistent with the developmental level of participants? 2. Is it consensual or coercive? 3. What is the motivation of the participants? 4. Is some outside influence involved? 5. What is the age difference between the participants? And 6. What is the response of the child to the episode? Normal sexual activity during childhood typically involves consenting, developmentally appropriate activities that are mutually motivated by curiosity and pleasure . . ."(p. 209).
• Hormonal factors: 1) In humans no relationship between androgen levels in males and sexual excitement, desire, and frequency. 2) In humans, no relationship between plasma estradiol levels in females and sexual arousal, gratification, or frequency. 3) Possible link between testosterone in females contributing to the level of arousal and sexual desire
  1) In humans no relationship between androgen levels in males and sexual excitement, desire, and frequency. 2) In humans, no relationship between plasma estradiol levels in females and sexual arousal, gratification, or frequency. 3) Possible link between testosterone in females contributing to the level of arousal and sexual desire
• Likely indicators of sexual abuse: Likely indicators of sexual abuse include but are not limited to the following: 1. Verbal report of sexual abuse by the child 2. Physical signs (e.g., STDs, pregnancy, or physical injuries) 3. Behavioral signs (e.g., depression, phobias, nightmares, hypervigilance, somatic complaints, anxiety, non-compliance, inappropriate sexual behavior, aggressiveness, poor self-esteem, or substance abuse). There is no single constellation of symptoms typical of the sexually abused child. Every child should be considered invidividually on the basis of their own physical, psychosocial and historical information.
  Likely indicators of sexual abuse include but are not limited to the following: 1. Verbal report of sexual abuse by the child 2. Physical signs (e.g., STDs, pregnancy, or physical injuries) 3. Behavioral signs (e.g., depression, phobias, nightmares, hypervigilance, somatic complaints, anxiety, non-compliance, inappropriate sexual behavior, aggressiveness, poor self-esteem, or substance abuse). There is no single constellation of symptoms typical of the sexually abused child. Every child should be considered invidividually on the basis of their own physical, psychosocial and historical information.
• Conditions often mistaken for sexual abuse: Conditions often mistaken for sexual abuse include but are not limited to: erythema of anogenital area (may be due to bubble baths, poor diaper hygiene, pinworms, candidal infection, inertrigo), phytodermatitits (e.g., from gentian violet used to treat Candida), Henoch-Schonlein purpura, lichen sclerosus, atopic dermatitis, seborrheic dematitits, psoriasis, impetigo, hemangioma of hymen, vulva, vagina or perineal body, congential structures of genetial area, anal fistulae or furnuncles, straddle injuries, or a variety of infectious conditions (e.g., streptococcal infection). Referrals for alleged sexual abuse should include a careful physical exam and a thorough psychosocial and medical history.
  Conditions often mistaken for sexual abuse include but are not limited to: erythema of anogenital area (may be due to bubble baths, poor diaper hygiene, pinworms, candidal infection, inertrigo), phytodermatitits (e.g., from gentian violet used to treat Candida), Henoch-Schonlein purpura, lichen sclerosus, atopic dermatitis, seborrheic dematitits, psoriasis, impetigo, hemangioma of hymen, vulva, vagina or perineal body, congential structures of genetial area, anal fistulae or furnuncles, straddle injuries, or a variety of infectious conditions (e.g., streptococcal infection). Referrals for alleged sexual abuse should include a careful physical exam and a thorough psychosocial and medical history.
• Assess for sexual abuse or any early, coercive or unintended sexual activity.: Trigger questions for OLDER CHILDREN: 1) Have you ever been touched sexually when you didn't want to? 2) Have you ever had intercourse? Touched or been touched by someone else? 3) Are you sexually active now? 4) Have you ever had sex when you didn't want to? Trigger questions for YOUNGER CHILDREN: 1) Where are your privates? What do you call them? (use whatever term the child uses but be clear to differentiate between anal and genital areas). 2) Has anyone ever touched [your privates] that you didn't want to?
  Trigger questions for OLDER CHILDREN: 1) Have you ever been touched sexually when you didn't want to? 2) Have you ever had intercourse? Touched or been touched by someone else? 3) Are you sexually active now? 4) Have you ever had sex when you didn't want to? Trigger questions for YOUNGER CHILDREN: 1) Where are your privates? What do you call them? (use whatever term the child uses but be clear to differentiate between anal and genital areas). 2) Has anyone ever touched [your privates] that you didn't want to?
• Gender Identity Disorder is usually before age 4: Problem or Variation level cross-gender behavior related to stressful life events usually has an onset of 4-7 years
  Problem or Variation level cross-gender behavior related to stressful life events usually has an onset of 4-7 years
• diagnosed until later.: Often children are referred at the time of school entry because parents notice that the gender confusion that they thought was just a "passing phase" has not yet abated.
  Often children are referred at the time of school entry because parents notice that the gender confusion that they thought was just a "passing phase" has not yet abated.
• Clinic referrals for boys are 5 times that of girls: May be due to the greater stigma that gender confused boys bear.
  May be due to the greater stigma that gender confused boys bear.
• Behaviors consistent with Gender Identity Disorder: Less serious manifestations of cross gender behavior may be diagnosed as a Variation or Problem . 1) Cross-Gender Variation is most often seen following stressful life events such as divorce, birth of sibling or a family death. 2) Cross-Gender Problem is cross-gender behavior that lasts for 6 months or longer and is pervasive across contexts but does not involve the rejection of one's gentitalia or permanent wish to be the other gender as is seen in GID.
  Less serious manifestations of cross gender behavior may be diagnosed as a Variation or Problem . 1) Cross-Gender Variation is most often seen following stressful life events such as divorce, birth of sibling or a family death. 2) Cross-Gender Problem is cross-gender behavior that lasts for 6 months or longer and is pervasive across contexts but does not involve the rejection of one's gentitalia or permanent wish to be the other gender as is seen in GID.
• Dislike of genitalia: Boys may express hating their penis; they may try to hide, hurt, get rid of it and may insist on urinating while sitting. Girls may express wanting a penis and may believe they will grow one; may insist that breasts will not develop or menstruation will not occur; may want to urinate while standing.
  Boys may express hating their penis; they may try to hide, hurt, get rid of it and may insist on urinating while sitting. Girls may express wanting a penis and may believe they will grow one; may insist that breasts will not develop or menstruation will not occur; may want to urinate while standing.
• Dressing in clothing of other sex: For boys dressing in girls clothing or simulating girls attire; for girls wearing masculine clothing, experiencing distress if put in a dress.
  For boys dressing in girls clothing or simulating girls attire; for girls wearing masculine clothing, experiencing distress if put in a dress.
• Prognosis: However, homosexuality or transsexualism are common among men who were identified with GID in childhood. The DSM-IV reports that approximately 75% of males who had a history of Gender Identity Disorder as young boys have a homosexual or bisexual orientation without GID as adults. Commensurate figures for girls are not known.
  However, homosexuality or transsexualism are common among men who were identified with GID in childhood. The DSM-IV reports that approximately 75% of males who had a history of Gender Identity Disorder as young boys have a homosexual or bisexual orientation without GID as adults. Commensurate figures for girls are not known.
• General Sexual Identity Trigger Questions: 1. Have you ever dated? 2. Have you ever been sexual with another person? 3. Are you attracted to girls, boys, or both? 4. Have you ever had sex with girls, boys, or both? 5. Do you protect yourself against STDs? 6. Do you have any concerns about your sexual feelings, attractions, or activities? 7. Have you discussed sex with your parents? Friends? Other adults?
  1. Have you ever dated? 2. Have you ever been sexual with another person? 3. Are you attracted to girls, boys, or both? 4. Have you ever had sex with girls, boys, or both? 5. Do you protect yourself against STDs? 6. Do you have any concerns about your sexual feelings, attractions, or activities? 7. Have you discussed sex with your parents? Friends? Other adults?
• GID Specific Trigger Questions: From the Gender Identity Interview Schedule. Appropriate for children 7 and older but can be used with younger children keeping in mind they may not have attained concrete operational thought and thus may not understand that gender is constant and immutable (e.g., Question 4). Three to four deviant responses indicate a high probability of gender confusion. Following is the boy version. 1. Are you a boy or a girl? 2. Are you a (opposite of first response)? 3. When you grow up will you be a Mommy or a Daddy? 4. Could you ever grow up to be (opposite of first response)? 5. Are there any good things about being a boy? [If yes, tell me some of the good things about being a boy] 6. Are there any things you don't like about being a boy? [If yes, tell me some of the things you don't like about being a boy] 7. Do you think it is better to be a boy or a girl? 8. In your mind, do you ever think you would like to be a girl? 9. In your mind, do you ever get mixed up and you're not really sure if you are a boy or a girl? [If yes, tell me some more about that] 10. Do you ever feel more like a girl than a boy? [If yes, tell me more about that] 11. You know what dreams are right? Well when you dream at night are you ever in the dream? If yes, ask: In your dreams are you a boy, a girl or sometimes a boy and sometimes a girl? [Probe as needed] 12. Do you ever think that you are really a girl? [If yes, tell me more about that]
  From the Gender Identity Interview Schedule. Appropriate for children 7 and older but can be used with younger children keeping in mind they may not have attained concrete operational thought and thus may not understand that gender is constant and immutable (e.g., Question 4). Three to four deviant responses indicate a high probability of gender confusion. Following is the boy version. 1. Are you a boy or a girl? 2. Are you a (opposite of first response)? 3. When you grow up will you be a Mommy or a Daddy? 4. Could you ever grow up to be (opposite of first response)? 5. Are there any good things about being a boy? [If yes, tell me some of the good things about being a boy] 6. Are there any things you don't like about being a boy? [If yes, tell me some of the things you don't like about being a boy] 7. Do you think it is better to be a boy or a girl? 8. In your mind, do you ever think you would like to be a girl? 9. In your mind, do you ever get mixed up and you're not really sure if you are a boy or a girl? [If yes, tell me some more about that] 10. Do you ever feel more like a girl than a boy? [If yes, tell me more about that] 11. You know what dreams are right? Well when you dream at night are you ever in the dream? If yes, ask: In your dreams are you a boy, a girl or sometimes a boy and sometimes a girl? [Probe as needed] 12. Do you ever think that you are really a girl? [If yes, tell me more about that]
• Intersex condition: If physical exam is normal, karyotyping and sex hormone assays are usually not needed. If a gender identity problem co-exists with a congenital intersex condition then code as Gender Identity Disorder NOS.
  If physical exam is normal, karyotyping and sex hormone assays are usually not needed. If a gender identity problem co-exists with a congenital intersex condition then code as Gender Identity Disorder NOS.
• Personality Disorders: More common among males than among females being assessed for gender disorder. (feels that they are the opposite sex)
  More common among males than among females being assessed for gender disorder. (feels that they are the opposite sex)
• Refer for psychological counseling.: Some evidence that treatment in childhood yields better outcomes than delaying treatment until adolescence. Duration of treatment is usually long term with 2-4 years being optimal.
  Some evidence that treatment in childhood yields better outcomes than delaying treatment until adolescence. Duration of treatment is usually long term with 2-4 years being optimal.
• Provide counseling and support on telling friends and family members: "Coming Out" may cause extreme anxiety, depression, cognitive impairment, or emotional lability
  "Coming Out" may cause extreme anxiety, depression, cognitive impairment, or emotional lability