Child and Adolescent Psychiatric Clinics of North America
Situating unusual child and adolescent sexual behavior in context
Section snippets
Child and adolescent sexuality in historical context
What is judged as “normal” and “unusual” sexual behavior is highly variable and dependent on social and cultural contexts. These sociocultural views ascribe meaning to sexual behaviors, and, therefore, shape the child's and adolescent's experience. The linking of sexual development priorities to appropriate sexual behaviors for children and adolescents could not transpire until the social category of adolescence was invented. Before this change, adolescents were treated as adults by society [3].
The sexual interests of prepubescent children
Sexual behaviors are typical of children at almost all ages—certainly after infancy—although they require definition relative to age and to a specific child. Prepubescent children do masturbate and have orgasms, although boys do not ejaculate. Childhood “sex” play probably is motivated more by curiosity than by sexual desire. Thus, dimensional qualities of temperament, personality, and cognitive potential play a role in sexual behaviors, whereas psychiatric or other organic illness or social
Healthy sexual interests among adolescents
Despite few data about what constitutes normal sexual interests among adolescents, we accept that healthy adolescents are interested in sexuality, have sexual desires and fantasies, and that most will masturbate. Typically, it is presumed that these interests will be heterosexual, coital, and eventually will lead toward monogamous relationships and marriage. There is considerable fear that if teens act on their desires, the results will be STIs, unintended pregnancies, and moral decay. Many
Legal versus illegal and immoral sexual acts
Whether a sexual behavior is deemed illegal depends on the jurisdiction in which it takes place [8]. Reputable psychiatrists cannot suggest or condone that minors engage in illegal acts or acts that seem to be illegal. Historically, it is evident that some behaviors are not deterred by legal constraints. Whether a sexual act is legal or illegal, morality is a separate issue. Again, reputable psychiatrists may have difficulty with suggesting or condoning behaviors that violate their own moral
“Normal” versus “unusual” or “abnormal” child and adolescent sexuality
The term “unusual” implies that the sexual activity in question falls outside of an expected range of sexual behavior for the specific age groupings or gender role norms; typically, a negative connotation is associated with the term. Children who refrain from exploring their sexuality or limit their sexual interests to social ideals are not considered to be unusual. Sex is one of the few domains in which being more “adult” or precocious is considered a liability.
The assessment of unusual sexual
Can a minor be diagnosed with a paraphilia?
The Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition (DSM-IV-R) indicates that paraphilias may begin in childhood but are manifest in adolescence and early adulthood [13]. Nevertheless, there has been ongoing, serious criticism of the diagnostic category of the paraphilias through several editions [10], [11], [12], [13], [14], [15], [16], [17], [18]. Unquestionably, there are people who suffer or bring distress to others because of their unusual sexual proclivities.
Defining unusual sexual interests
We do not want to repeat the mistake of identifying specific, unusual sexual behaviors as pathologic, particularly without the data to substantiate such classifications. Naming and classifying particular, unusual behaviors allows for the inference that other, unclassified (ie, more or less common) behaviors are unlikely to be the source of difficulties. For the purposes of this article, unusual sexual interests are discussed in terms of the following considerations.
Dangerous sexual behaviors
Dangerous sexual behaviors are various and potentially extensive in scope and might be considered unusual behaviors by fiat; they are discussed only briefly. Such behaviors include danger to self and danger to others. Boys, especially pubescent ones, are overrepresented in this category. Self-danger most commonly involves placing objects or instruments into, or circumscribing, the genitalia or placing the penis into a dangerous object. Preschool girls may place foreign objects (eg, crayons,
Anxiety-provoking sexual behaviors
Some sexual behaviors are unusual in that they create anxiety in the parent (or other adults) or in the child. Accidental or intended exposure of the child to adult sexual intercourse may create anxious reactions in the child or anxious responses in the parent. Additionally, sexual behaviors by themselves, especially exhibited by the younger preschool child, may provoke anxiety in the parent and reactive anxiety in the child. Exposure to pornography may create similar clinical pictures as can
The role of the clinician
Generally, unusual sexual behaviors respond well to cognitive, educational approaches for parents, patient, other adults, or a combination of these; therefore, these interventions generally are strongly goal-oriented and brief in duration. When the operative drive is erotic, however, short-term goals may be ineffective. Support groups may benefit some parents or children in these situations. Providing longer-term sexual therapy to the child that assists him in bridging his erotic drive to be
Sexual silence
Most typical adolescents attempt to be discreet about their sexual conduct. For adolescents who have concerns about their sexual interests, the prospect of confiding in an adult can be a daunting prospect. It is even worse for those who have kept their predilections secret but are discovered, especially if their sexual behaviors are unusual. For adolescents or children who have been identified as having psychologic problems (or especially sexual problems), it often is more difficult to keep
Sex education or more silence
There is a great deal of controversy about sexuality education in American society. Abstinence-only sex education is the only approach that is funded by the federal government. This is aimed at convincing teens not to engage in sex. Such curricula sanction teaching questionably accurate “facts” (eg, condoms are ineffective, any sex will lead to pregnancy and disease, and the inability to refrain from sex indicates moral weakness or psychologic problems). Under abstinence-only sex education
Sexual meanings in childhood and adolescence
Despite the concerns of society and parents, children do engage in sexual acts alone as well as with others. Some adults think that positive discussion about sex will lead to inappropriate and premature experimentation. Others suggest that the lack of honest and clear information leads to an increase in unusual [40] and unsafe sexual practices [41]. Although we have little data in regards to these claims, it is important to give positive sexual messages to children and to avoid associating
Sexual behavior for “nonsexual” purposes
Adolescents may use their sexuality for purposes other than sexual pleasure. By being seductive or overtly sexual, they may gain peer status; access the adult world; obtain possessions (eg, clothes or money) or the feeling that they are valued, powerful, and in control. This process risks placing adolescents in the position of being exploited and entangling their self-worth with the willingness to exchange sex for other commodities. Similarly, children may be drawn into sexual activities that
What do we know about the genesis of unusual sexual behavior?
How individuals develop their unusual sexual interests is not known. It is clear, however, that children develop—or at least possess—sexual interests. These interests may wane, evolve, or be integrated into adult sexual patterns. From our clinical experience, most adults and teenagers who engage in unusual sexual behavior recognize that their desires were present in early childhood. Sometimes, parents recognize early patterns of such behaviors retrospectively. When confronted with the
The role and impact of sexual abuse
A prevalent and typical assumption in the literature is that unusual sexual behaviors are caused by child sexual abuse [43], [44], [45], [46], [47]. The data to support this statement are lacking and many other possible explanations exist (eg, family dynamics, genetic predispositions, lovemaps) [48]. Additionally, our clinical experience negates generalizing the assumption that unusual sexual behaviors are caused by sexual abuse.
There is much concern that those who have been abused will abuse
Research on normal and unusual adolescent sexual behavior
Research on normal adolescent sexual behavior has been problematic; typically, the primary focus has been on behavioral events, such as age at first intercourse, contraception, and sexually transmitted disease. Such focus inevitably imbues findings with negative meanings [62], [63]. Questions about unusual or noncoital behaviors and fantasies in normal adolescent populations are ignored [63]. Given the current politics of sex research and the sex-negative attitudes of American society, it is
Unusual sexual interests and concurrent psychiatric concerns
Underlying psychosexual development may effect, and be affected by, unusual sexual interests. For example, in children who have unusual sexual interests, underlying impulse control difficulties may stimulate, or be stimulated by, sexual interests. Yet neither impulse control nor unusual sexual interests necessarily is a sign of enduring pathology. Focusing interventions on the more readily treated problem may help to resolve the other.
Lack of impulse control, however, may be important in
Summary
Our understanding of unusual sexual interests in children and adolescents is in its infancy. This article attempts to position the topic in its overall context. Social and legal proscriptions may have a greater impact on how clinicians regard unusual sexual behavior than does knowledge. Defining unusual sexual behaviors is complex. Determining individuals in whom the behavior will endure or become worrisome is a further challenge for issues of social safety as well as for clinical intervention.
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