What Are Common Sexual Behaviors in Young Children?

Patient Presentation
A 3-year-old male came to clinic for his health supervision visit. His mother had no real concerns but stated that since he was toilet training she had noticed that he also was doing a fair amount of masturbation. “I haven’t said anything to him but he’s doing it at the grocery store or at the playground with other people around. I’m not sure what to do or say,” she stated. During the interview the mother also said that he did not seem to have other worrisome sexual behaviors nor was she worried that he might have been sexually abused.

The pertinent physical exam showed a healthy male with growth parameters at the 90-95%, with normal vital signs. His examination was normal including noting that he was circumcised with bilateral testicles in the scrotum. The diagnosis of a healthy male was made. The pediatrician, responded that masturbation in a child of this age appeared to be normal as the behavior did not cause him distress, he did not have other sexual behaviors and was otherwise well. He recommended that the mother start to help him set appropriate personal boundaries by stating something like, “I know that rubbing your penis feels good, but that is only something you can do in private by yourself. You can do that in your bedroom or in the bathroom, but you shouldn’t do it at the playground with other people around.” The pediatrician also recommended that the mother teach him proper names for male and female genitals. As he probably would be asking more specific questions about body parts and bodily functions, the pediatrician recommended to answer the questions in a straightforward manner and use that as an opportunity to teach him about his growing sexuality.

Discussion
People of all ages, including both ends of the age spectrum, are sexual beings. It is a part of being human. Children will learn about their own and others sexuality both verbally and physically. Normative studies of young children’s sexual behavior were done in the 1990′s and showed a wide array of normative verbal and non-verbal behaviors at different ages, from potentially innocuous (i.e. stands too close to people) to potentially invasive (i.e. touches private parts of other children). Children who exhibit the most sexual behaviors are those < 4 years with basically a steady decline starting around 5 years of age. This is true for both sexes. This may be due to children learning that these are private behaviors and thus parents are less likely to see and report the behaviors.
Some parents worry that discussing sexuality will encourage sexual behaviors. Data does not support this viewpoint. Pediatricians and other health care providers can help educate families that teaching their children about sexuality is important. Providing straightforward answers gives the children information so they can make good choices about their own bodies and health which affects them directly and their families and communities indirectly. Parents are often concerned that the behaviors they notice are not normative and that they will not be able to answer their children's questions.

Some basic information for parents to consider when discussing sexuality with their children includes:

  • Offer simple, accurate information for the question being asked. Depending on the child’s age and knowledge, offer simple basic information about bodily functions including urination, defecation, puberty, sexual reproduction, pregnancy and childbirth.
  • Have the child re-ask the question or explain their question so parents can make sure they are answering the correct question.
    Children will often ask a question that adults mis-interpret. For example, a 3 year old child asks, “Where do babies come from?” When asked to repeat it, the child states, “Do babies come from mommies or grandmas too?”
    After the explanation if the child seems confused or not satisfied with the answer, ask “What doesn’t make sense?” or “What else can I answer for you?” This lets the child clarify the answer or ask other questions.

  • Make and reinforce personal boundary rules such as private parts should be covered, one does not touch other people’s private parts, touching private parts should occur only in private
  • Provide accurate names for male and female body parts from the onset
  • Masturbation is a normal behavior at any age, but it should be done in private
  • In older children, provide basic information about sexual activity risks including pregnancy and contraception, sexually transmitted infections and prevention methods
  • Provide sexual safety information such as your body belongs to you. The child can say NO at any time if someone’s touches makes them feel bad. Teach ways to avoid risky situations such as stranger safety and dating rules.
  • Even if parents are uncomfortable that they may say something wrong, they are communicating with the child and trying to answer their questions. Its okay to say, “I don’t know” and then find an answer. A child is more likely to continue to talk about sexuality and other topics with the parent if all communication at home is open.

Parents and healthcare providers should be concerned if any sexual behaviors include anything that:

  • Is clearly beyond the child’s developmental age
  • Involves children of widely different ages
  • Causes strong emotions in the child
  • Involves aggression, threats or force

Learning Point
Common sexual behaviors in children < 12 years old includes:

  • < 4 year old
    • Asks questions about own/others body and bodily functions
    • Talks with children of same age about bodily functions
    • Removes clothes and wants to be naked
    • Show other people his/her own private parts
    • Tries to see other people who are undressing or naked
    • Explores or rubs private parts (with hand or objects) in private or public
  • 4-6 year olds
    • Talks about private parts and uses slang (i.e. “naughty”) words. May not understand the word he/she is using
    • Tries to see other people who are undressing or naked
    • Masturbates in private or occasionally in public
    • Explores private parts with children of own age (i.e. plays doctor)
    • Mimics dating behaviors such as hand holding or kissing
  • 7-12 year olds
    • Beginnings of sexual attraction or interest in peers
    • Desire for privacy increases such as locking bathroom doors, not wishing to un/dress in front of others.
    • Tries to see other people who are undressing or naked
    • Views/listens to media with increased sexual content
    • Views media of naked or partly naked people
    • Masturbates usually in private
    • Plays games that involve sexual behavior with same age peers (i.e. “boyfriend/girlfriend” “truth or dare”)

Questions for Further Discussion
1. What are normative sexual behaviors for teenagers?
2. What types of sexual behaviors may indicate that a consultation with a child maltreatment specialist is indicated?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sexual Health, Toddler Development and Teen Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Friedrich WN, Grambsch P, Broughton D, Kuiper J, Beilke RL. Normative sexual behavior in children. Pediatrics. 1991 Sep;88(3):456-64.

Friedrich WN, Fisher J, Broughton D, Houston M, Shafran CR. Normative sexual behavior in children: a contemporary sample. Pediatrics. 1998 Apr;101(4):E9.

National Child Traumatic Stress Network. Sexual Development and Behavior in Children. Available from the Internet at http://nctsn.org/nctsn_assets/pdfs/caring/sexualdevelopmentandbehavior.pdf (rev. 4/2009, cited 5/28/2013).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Gun Violence Is a Public Health Measure

    Patient Presentation
    A 7-year-old female came to clinic for health supervision. She was growing and developing appropriately. During the social history, the pediatrician asked if there were any guns in the home. The father answered that yes there were long guns used for target practice and occasional hunting. When she asked about safety measures such as trigger locks, gun cabinets, or keeping ammunition separated, the father said that the guns were in his closet along with the ammunition. The pediatrician recommended that the guns be taken out of the home, but also said that if the guns remained then they should be kept in a gun safe where they could be stored unlocked with a individual trigger lock on each gun. Also she recommended that the ammunition be stored in its own separately locked container. The father seemed partially annoyed but also partially puzzled and asked questions about why trigger locks were recommended. The pediatrician replied that this was an inexpensive way to make sure the gun wasn’t discharged by accident. “The trigger locks are about $10-15 each, and an ammunition safe or lock box starts around $60. It’s a lot less expensive than the cost of having a gun injury,” she replied.

    The diagnosis of a healthy girl living in a home with guns was made. During a subsequent acute care visit, the mother said that the father had transferred the guns to the gun safe at her in-laws home. They also now had trigger locks on them. “I never liked having them in our house. At least they are locked up over there and my husband can get to them when he wants but they are not in my house.”

    Discussion
    For anyone, general access to guns is one major reason fatalities and injuries. If a gun is not available then it simply cannot be used. In pediatric patients, younger children are simply curious about the world and will explore everything, including guns, that they find without any understanding of the danger. Older children developmentally are not able to discern the difference between the fantasy world of videogames, movies and television and may not understand that people truly are hurt or killed by guns. Somehow in the fantasy worlds, the hero or player always seems to be able to come back to life. Teens and young adults often do not have the judgment to not act impulsively. Fights, wayward emotions and a gun in the environment can bring about tragedy in an instant. Additionally there are homes where mental illness, substance abuse, and many other stressors can turn the availability of a gun into a disaster.

    With these pediatric developmental considerations in mind, the American Academy of Pediatrics’ policy on Firearm-Related Injuries Affecting the Pediatric Population states that “Firearm-related injuries are often fatal; primary prevention is essential.” It further states that “…the most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes and communities.” [emphasis added.] It additionally recommends that parents should be counseled regarding the presence and availability of firearms and to encourage parents to prevent access. Recognizing that the safest home is one without guns, parents should also be counseled about safe gun storage including ways to limit access such as gun cabinets or other locked storage containers, individual firearm trigger locks, and separate locked storage containers for ammunition. Additional concerns should be reinforced in homes where there are patients with “mood disorders, substance abuse problems (including alcohol), or a history of suicide attempts.” Individuals in these homes are at an increased suicide risk.

    A recent study has shown that increased strength of state firearm laws is associated with a lower overall firearm fatality rate, homicide rate and suicide rate for that state. That is stronger firearm laws is associated with lower firearm fatalities. “The AAP [also] recommends restoration of the ban on the same of assault weapons to the general public.”

    Learning Point
    Public health is “the science and practice of protecting and improving the health of a community, as by preventive medicine, health education, control of communicable diseases, application of sanitary measures, and monitoring of environmental hazards.” Public health measures have been effective in disease prevention, improving traffic fatalities, etc.. Public health measures have helped to decrease pediatric morbidity and mortality such as car safety restraints, medication packaging, drug development for cancers, implantable devices for hearts, vaccines for infectious diseases, etc. Unfortunately this is not true for firearms. In the United States the number of firearm fatalities has been increasing over the last decade with ~31,500 people per year. By 2015, firearm fatalities are expected to surpass motor vehicle fatalities overall. In the 0-24 year population, the only group that does not have homicide or suicide as one of the top 4 causes of death is in the under 1 year group. A 2009 study of violent deaths in the US found that firearms were involved in 51.8% of suicides and 66.5% of homicides. Firearms were the leading cause in both cases.

    Gun related fatalities are twice the number of cancer fatalities, 5 times the number of heart disease and 15 times the number of infectious diseases. In 2010, the number of firearm fatalities in children and young adults 0-24 years was 6,462. Whereas over the last 10 years, all the vaccine preventable diseases (incidence only not fatalities) was 3,948 when pertussis was excluded. To see a table of the top 10 causes of death by age group, click here.

    Gun violence is a public health problem that needs multimodal solutions. Health care providers need to continue to educate the general public to view gun violence as a public health measure so children and parents will understand how they can decrease their own risk. Engaging lawmakers and other community stakeholders in helping to make appropriate regulations and laws improve the health and safety of the general community. Public health methodologies are multimodal and have been successful. It is time to apply them in earnest to this growing public health danger.

    Questions for Further Discussion
    1. What are the fatality rates for firearm violence in different countries? How does this stratify by war zone?
    2. What are the local resources for firearm safety training?
    3. What advocacy efforts are available in your local community to prevent firearm violence?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Teen Violence and Gun Safety.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    The American Heritage® Stedman’s Medical Dictionary. Houghton Mifflin Company.
    Available from the Internet at http://dictionary.reference.com/browse/public+health?s=t (rev. 2002, cited 5/21/13).

    Christoff C, Kolet I. American Gun Deaths to Exceed Traffic Fatalities by 2015.
    Available from the Internet at http://www.bloomberg.com/news/2012-12-19/american-gun-deaths-to-exceed-traffic-fatalities-by-2015.html (rev. 12/19/2012, cited 5/21/2013).

    Karch DL, Logan J, McDaniel D, Parks S, Patel N; Centers for Disease Control and Prevention (CDC). Surveillance for violent deaths–National Violent Death Reporting System, 16 states, 2009. MMWR Surveill Summ. 2012 Sep 14;61(6):1-43.

    Dowd MD, Sege RD; Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012 Nov;130(5):e1416-23.

    World Health Organization. WHO vaccine-preventable diseases: monitoring system. 2012 global summary.
    Available from the Internet at http://apps.who.int/immunization_monitoring/globalsummary/incidences?c=USA (rev. 2012, cited 5/21/2013).

    Palfrey JS, Palfrey S. Preventing gun deaths in children. N Engl J Med. 2013 Jan 31;368(5):401-3.

    Centers for Disease Control. Fatal Injury Data. Available from the Internet at http://www.cdc.gov/injury/wisqars/leading_causes_death.html (rev 9/12/2012, cited 5/22/13).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Professionalism
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What is the Criteria for Diagnosing Beçhet's disease?

    Patient Presentation
    An 8-year-old male came to clinic with an infected scratch/abrasion on his right arm caused by a stick that he had received the night before while playing in a wooded area. The wound had been cleaned by his mother but in the morning was red and swollen without discharge. It was mildly tender. He had no fever. The past medical history revealed that he had Beçhet’s disease and was immune suppressed because of his treatment. He was originally diagnosed after having oral and genital ulcers, and uveitis. His immunizations were current. The family history was positive for rheumatoid arthritis. The review of systems was otherwise negative.

    The pertinent physical exam showed a healthy appearing male with normal growth parameters. He was afebrile. An 8 cm linear abrasion was seen on the dorsal surface of the upper forearm near the elbow. It was mildly edematous with .75 cm erythema surrounding the lesion. The lesion appeared clean without retained foreign material or discharge. There was full range of motion in the elbow and forearm. There was no axillary lymphadenopathy. The diagnosis of mild cellulitis in an immunocompromised patient was made. The area of erythema was marked with a pen. The patient and family were instructed to keep the wound clean and dry and apply warm packs for comfort. Oral cephalexin was also prescribed. Instructions to monitor the lesion closely were made and when to call the clinic were given. The treating physician also sent a message by the electronic health record to his rheumatologist so she would also be aware. The patient’s clinical course the next day showed that the edema and erythema were markedly improved with regression of both and he had almost no pain either.

    Discussion
    Beçhet’s disease (BD) is a multisystem vasculitis named for the Turkish dermatologist, Hulusi Beçhet. It has a prevalance in one study of 5.2-7.1 per 100,000 adults. It is more common in males than females but it depends on the cohort studied and there is variation among different ancestral groups.

    Venous vasculitis usually causes thrombotic events whereas arterial vasculitis causes aneurysms and thrombosis. Involvement of the central nervous system vasculature can be a major problem. Central venous thrombosis can cause isolated intracranial hypertension but also aphasia, hemiparesis and seizures. Pulmonary aneurysms are the leading cause of death in adults. Unlike many other autoimmune diseases BD usually does not affect the kidney. Gastrointestinal disease may be seen such as diarrhea and abdominal pain. Nonerosive arthritis particularly of the knees is also seen.

    The actual cause is unknown but it is associated with several genetic factors including HLA-B5.

    As this is a syndrome there is no specific testing but other tests are done to exclude other diagnoses. ESR and C-reactive protein may be slightly elevated. Anti-nuclear antibodies, antineutrophil cytoplasmic antibodies and rheumatoid factor are usually negative. Treatment depends on the organ involvement including topical treatment for ulcers, and antiinflammatory medications for more serious disease. Azothioprine is often used for uveitis and cholchicine for nodules of the skin. CNS involvement may include multimodal treatment with combinations of azothioprine, cyclophphamide, interferon-alpha, mexthotrexate, steroids, and tumor-necrosis factor.

    Learning Point
    Criteria for the diagnosis of Beçhet’s disease includes:

    • Recurrent oral ulcers – aphthous ulcers are most common
    • Plus 2 of the following:
      • Eye disease – including anterior uveitis, panuveitis, and hypopynon (white blood cells in the anterior chamber is almost pathognomonic in the proper clinical setting)
      • Genital ulcers – usually scrotum or labia
      • Skin lesions – acneiform lesions similar to acne vulgaris but in atypical locations such as extremities, erythema nodosum is also seen. Superficial thrombophlebitis may be confused with erythema nodosum
      • Positive pathergy test – skin is sterilly pricked and 48 hours shows a pustule or papule.

    Questions for Further Discussion
    1. What other diseases are in the differential diagnosis for Beçhet’s disease?
    2. What are indications for referral to a rheumatologist and/or immunologist?
    3. What are some ways that primary care physicians and specialists can work together to provide quality care to patients?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Bechet’s Syndrome

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Ozen S. Pediatric onset Behcet disease. Curr Opin Rheumatol. 2010 Sep;22(5):585-9.

    Saddoun D. Wechsler B. Bechet’s Disease. Orphanet J Rare Dis. 2012 Apr 12;7:20.

    Yazici Y. Bechet Syndrome. ePocrates.
    Available from the Internet at https://online.epocrates.com/noFrame/showPage.do?method=diseases&MonographId=376&ActiveSectionId=11 (rev. 12/13/2012, cited5/14/13).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital