Childhood sexuality: discerning healthy from abnormal sexual behaviors.

Empirically determined characteristics that mental health counselors can use as a reference when assessing the normalcy of sexual behaviors in preadolescent children are summarized. Once sexual behaviors have been determined to be problematic, mental health counselors need to be aware of and address factors that will affect children's sexual attitudes and behaviors.

**********

Mental health counselors are often asked to determine whether a preadolescent child's sexual behaviors are normal or problematic. Pairing sexuality with children makes many parents and mental health counselors uncomfortable. Parents are concerned and often confused about the most appropriate ways to respond to their children's emerging sexuality, and parents often consult mental health counselors to determine whether their children's sexual behaviors are indicative of a problem or merely normal childhood development. Because researchers have found that there is a direct correlation between the frequency of childhood sexual behaviors and sexual abuse (Beitchman, Zucker, Hood, DaCosta, & Akman, 1991; Friedrich, 1993; Friedrich & Grambsch, 1992; Kendall-Tackett, Williams, & Finkelhor, 1993), many mental health professionals feel an urgency to correctly determine the source of the child's sexual behaviors. It is important that mental health counselors have the ability to define what constitutes appropriate and inappropriate sexual behaviors in children. The purpose of this article is to identify normal and abnormal childhood sexual behaviors and to examine factors that mental health counselors should be aware of as contributing to children's problematic sexual attitudes.

NORMAL SEXUAL BEHAVIORS

Psychosexual development begins in infancy and progresses with age, along with the other realms of development. At birth, boys are capable of having erections, and girls' vaginas are capable of lubrication (Johnson, 1999). Children's sexual development is marked by curiosity about, first, their own bodies and, then, those of others (Schuhrke, 2000). Children's attempts at sexual exploration and the repercussions of these attempts help to shape the child's sexual development (Mrazek & Mrazek, 1987). Children learn when they are allowed to satisfy their sexual curiosities as well as when they are not allowed to. Some parents are able to respond to children's emerging sexuality in a caring, healthy manner; yet others feel threatened and react harshly. Adults' and other children's shame and embarrassment often play a role in a child's developing modesty and inhibition (Schuhrke).

Many sexual behaviors in children are common, and the variability of those normative behaviors is extensive (Friedrich, Grambsch, Broughton, Kuiper, & Beilke, 1991; Hibbard, Roughmann, & Hoekelman, 1987). Friedrich et al., using the sexual behavior items from the Child Behavior Checklist (CBL) and the Child Sexual Behavior Inventory (CSBI), performed a comprehensive benchmark study to determine what sexual behaviors were normal in the preadolescent population. This study is unique because it is one of very few known to examine nonclinical samples of children. The researchers relied on parental report for their data on 2-through 12-year-old children without a history of suspected or confirmed sexual abuse. In identifying sexual behaviors of boys and girls 2-6 and 7-12 years of age, the researchers found that the frequency of some observed sexual behaviors commonly decreased (i.e., undresses other people, wants to be the opposite sex, rubs body against people, shows sex parts to children, touches sex parts in public) or increased (i.e., looks at nude pictures, uses sexual words, asks to watch explicit television) with age in either or both genders. Some behaviors, such as imitates sexual behavior with dolls, inserts objects into vagina/anus, talks flirtatiously, and pretends to be the opposite sex, were noticeably more common in girls than in boys. Conversely, behaviors observed more frequently in boys than in girls included making sexual sounds, looking at nude pictures, touching sex parts in public, and trying to look at people undressing. Friedrich et al. found that all sexual behaviors assessed occurred in at least one of the groups. Although some behaviors were much less common (i.e., puts mouth on sex parts, asks to engage in sex acts, inserts objects in vagina/anus, masturbates with objects, initiates intercourse), they still occurred to some extent, thus making it inappropriate to determine any of these behaviors to be indisputably abnormal. Similarly, Hibbard et al. reported that few 3-to 7-year-old children draw genitalia on drawings of the human figure; however, some do.

Children's exhibiting interest in their own genitals and those of their parents is a normal phase of childhood sexual development. Genital play has been found to be a common sexual behavior in children from infancy to at least 6 years old (Johnson, 1999; Koocher et al., 1995; Larsson & Svedin, 2002; Mrazek & Mrazek, 1987; Schuhrke, 2000). Children will often masturbate and show an interest in the genitals of others. Interest progresses from their own genitals, to their parents' genitals, and then to those of their siblings and peers. Schuhrke found that children commonly touch others' genitals in the 2nd and 6th years of life. Possibly due to naivete, younger children, playing sexual games such as "doctor" and examining one another's bodies, are caught more often than older children. Mrazek and Mrazek discuss another aspect of normal sexual development in which preschool children exhibit "a fascination with sexuality which can become associated with an intense attachment to a parent" (p. 21). Freud referred to this occurrence as the Oedipal complex. Mrazek and Mrazek claim that a healthy resolution of this phase is at least partially dependent upon the parents' reactions and their understanding of the differences between adult and normal childhood sexuality.

Observers must be careful, when analyzing childhood sexual behaviors, to remember that a child's experience of sexuality is not the same as an adult's (Johnson, 1999). Adults possess a learned component to their sexuality that children have not yet acquired. Sexuality in adults is generally characterized by a passionate, erotic quality that children lack. A preadolescent child's mind is not capable of operating in the same manner as an adult's. Adults, using formal operational thinking (Piaget, 1965/1997), have the ability to perceive sexual experiences abstractly. Preadolescent children are still in the preoperational and concrete operational cognitive stages (Piaget) and experience sexuality, for the most pan, in the here and now and in a more concrete manner. Children's sexual feelings appear to be directly linked to sensuality and attachment (Johnson). Although some children's sexual comments appear to be motivated by a more adult understanding of sex, the child is often only conveying a surface meaning in the comments. For example, a young boy removed his underwear and commented that he "won't be needing these" any longer as he climbed into bed with his mother (Rothbaum, Grauer, & Rubin, 1997). Although the behavior could be construed as the boy planning to seduce his mother, he, in fact, planned nothing further and only prepared to fall asleep.

Rademakers, Laan, and Straver (2000) examined body awareness and physical intimacy experiences from a child's perspective in 8-and 9-year-olds. The researchers asked the children questions relating to romping, cuddling, and being in love. Physical intimacy was valued by almost all of the children in the study, and the majority of the children reported that romping and cuddling were enjoyable experiences involving their whole bodies. In addition, the study found that children experienced being in love in some ways like adolescents and adults do, as a tickling sensation: "It makes you feel proud," and "you feel it near your heart, and you get red all over" (p. 54). Although children fantasized about the person they were in love with, these were relatively innocent fantasies (i.e., holding the person or playing with him or her).

Johnson (1999) has identified some distinct characteristics of normal childhood sexual exploration. Children experience normal sexual exploration with positive, healthy feelings. Children's sexual exploration is often observed as lighthearted, silly, spontaneous, and giggly; and although it may result in embarrassment at times, it is uncommon for it to involve anger, shame, fear, or anxiety. Most children experience pleasurable sensations and arousal, and some even experience orgasm, although orgasm generally occurs more readily during puberty. Children normally experiment with other children who are within a year of their chronological or developmental age, and participation is on a voluntary basis in normal experimentation. Although some siblings experiment sexually, it is much more common for the other child to be a friend that the child plays with often. Sexual interest and activity, on average, is equal between boys and girls; and children normally range from having no interest in sexual play to being very interested. The children's interest in sexuality is balanced by their curiosity about the other aspects of their life. Normal sexual experimentation is spontaneous and sporadic, not something that the child is persistently preoccupied with. Learning about sex and feeling positively about it is part of a child's healthy sexual development.

Friedrich et al. (1991) found that overt sexual behavior, after peaking in the 3-to 5-year-old period, decreases as children begin to enter school. This observed difference could reflect an actual decrease in the behaviors or be the result of children learning modesty and, therefore, hiding their sexual behaviors from parents more often. In a comparison of American attitudes toward sexuality to those of other countries, Dutch (Friedrich, Sandfort, Oostveen, & Cohen-Kettenis, 2000) and Swedish families (Larsson & Svedin, 2002) were found to have more sexually permissive views than Americans and, perhaps, more tolerance for childhood sexuality. Dutch and Swedish children were reported by their parents to display a significantly higher frequency of sexual behaviors than American children, maybe because Dutch and Swedish parents were more accepting of their children's sexuality and, therefore, more willing to label behaviors as sexual. It could also be that Dutch and Swedish parents were more accepting toward and perhaps even encouraging of their children's sexual behaviors. Friedrich et al. (1991) also determined a positive relationship between family nudity and the frequency of observed childhood sexual behaviors at all age levels. Families that are less concerned about letting children see adults nude may be more accepting in their attitudes regarding sexuality.

SEXUAL BEHAVIORS ELICITING CONCERN

There are some particular characteristics of a child's sexual behavior that mental health counselors can use as an indicator of inappropriateness (Johnson, 1999). Children experimenting sexually with children who are not their normal playmates and/or are not within a year of their developmental of chronological age is cause for concern. Because children who are used for the sexual pleasure of an adult will often generalize this behavior, adults may notice that these children misconstrue nonsexual people, objects, or relationships as sexual. Therefore, it is a warning sign when a child consistently directs sexual behaviors at adults. Adults should be concerned when they discover children possessing sexual knowledge or behaving in ways more consistent with adult sexual expression. There are various sources that can contribute to this age-inappropriate knowledge, and it can be important to determine the origin.

When sexual behaviors elicit complaints from other children, there is usually a sexual behavior problem that needs to be addressed. Normal sexual behaviors do not cause emotional or physical pain or discomfort to the child or others. If there is fear, anxiety, deep shame, or intense guilt associated with sexual behaviors, there is cause for concern because children do not normally use coercion, force, bribery, manipulation, or threats associated with sexual behaviors (Johnson, 1999). A child justifying his or her behaviors with distorted logic is another warning sign, for example, when one child says "no" to sexual play, but the other child continues and insists that the first child really wanted to participate in the sexual behavior.

Children engaging in extensive, persistent, mutually agreed upon behaviors with other children is indicative of a sexual problem even though both parties are in agreement (Johnson, 1999). Often, when children feel very isolated and/or lonely, in order to fill an emotional void, they will seek out other children to perform sexual behaviors with. This sexual relationship may sometimes occur between siblings who have parents who are severely emotionally unavailable. There is cause for concern any time children's sexual curiosity seems out of balance with interest in other aspects of their lives.

FACTORS CONTRIBUTING TO NEGATIVE SEXUAL BEHAVIORS

Direct physical child sexual abuse has been empirically shown to have a wide-ranging number of detrimental effects on children (Browne & Finkelhor, 1986; Friedrich, Jaworski, Huxsahl, & Bengtson, 1997; Kendall-Tackett et al., 1993; McClellan et al., 1996). However, there are factors other than direct physical sexual abuse that may influence a child's sexual development in a negative manner, and these must be taken into account and examined on an individual basis (Friedrich & Grambsch, 1992; Johnson, 1999).

Children's borne environments greatly affect their sexual behaviors (Johnson, 1999). If their home is in a neighborhood with obvious prostitution and drug abuse, children may acquire some confusing messages about sex. Some parents allow children to watch pornographic videos and explicit television. Children are sometimes exposed to song lyrics and internet chat rooms that give them negatively distorted sexual ideas that can manifest in sexual behaviors. These same distortions can come from listening to parents or other adults joke about or discuss sex in an aggressive, angry, or jealous manner. It is also detrimental for a child to consistently hear an adult speak about members of a particular gender with negative sexual comments. Some homes have little or no sexual or emotional privacy, and so children may hear about their parents' sexual problems or may witness them having sexual intercourse, sometimes with alcohol and drugs involved. Some children witness their parent using sex in exchange for drugs, money, or safety. Children who witness domestic violence, especially when sexual language is used, and are subjected to physical and/or emotional abuse may develop inappropriate sexual behaviors and attitudes.

Parents who are lonely may handle their child's emerging sexuality in an inappropriate manner, letting the child take on the role of their partner (Mrazek & Mrazek, 1987). Perhaps this relationship does not involve actual sexual contact, but the parent will relate to the child in a manner usually reserved for a mate (e.g., parent and child sleep together, go on "dates," and/or discuss adult problems such as finances). Often these parents foster and covertly encourage the child's sexual attraction to them during the phase when it is normal for the child to experience these feelings, rather than help the child resolve the attraction in a healthy manner (Mrazek & Mrazek). This emotional response by parents can result in direct physical sexual abuse in time.

IMPLICATIONS FOR MENTAL HEALTH COUNSELORS

Children's sexual behaviors must be examined in context. Children displaying one or two of the identified negative characteristics may not have a serious problem; however, mental health counselors should be concerned about a child exhibiting more than two inappropriate sexual behaviors (Johnson, 1999). In addition, the Child Sexual Behavior Inventory (Friedrich & Grambsch, 1992) can be used when identifying problematic sexual behaviors. The 38-item CSBI has been found to be a reliable and valid indicator of sexual-abuse-related sexual behaviors in 2-to 12-year-old boys and girls (Friedrich et al., 2001). However, the CSBI is not meant to be the sole determinant of sexual abuse. Moreover, it is not the responsibility of mental health counselors to investigate whether sexual abuse has occurred. Legally, every state requires mental health professionals to report suspected child abuse of any kind to the proper authorities (O'Malley, 2002). It is very important, therefore, that all mental health professionals make themselves familiar with their states' laws and regulations associated with suspected and confirmed child sexual abuse. For more information regarding national reporting procedures, mental health professionals may reference the national child abuse hotline (National Child Abuse Hotline, 2002). Regardless of whether an assessment suggests normal, problematic, or suspected sexual-abuse-related sexual behaviors, the mental health counselor can work with the child and non-offending parents or guardians to examine and modify the child's sexual behaviors.

Working with a child's parents or guardians can be valuable both in determining the normalcy of a child's behaviors and in treating a child's abnormal sexual behaviors. The results of available studies on childhood sexual behaviors point to cultural and familial attitudes being important factors to consider when mental health counselors are assessing the frequencies of sexual behaviors in children (Friedrich et al., 2000; Johnson, 1999; Larsson & Svedin, 2002). Parents can help the mental health counselor understand the family's culture regarding sexuality and can be instrumental in tailoring the home environment in a way that helps the child to have appropriate sexual behaviors in public. For example, if parents practice nudity at home with their 4-year-old son and choose to ignore his behavior when he masturbates in front of them in their home, the child may not understand why he cannot masturbate in front of others at his daycare. The parents can help the child by setting the limit that he may only masturbate in private at home.

When parents are less accepting of their child's emerging sexuality and the accompanying normative behaviors, mental health counselors can often alleviate some parental discomfort by helping them to become aware that they are viewing the child's sexuality through an adult's lens. The child's experience is quite likely somewhat more innocent than the adult is interpreting it. For instance, if a mother has strict beliefs that her 5-year-old daughter should not be touching her own or her playmates' genitals under any circumstances, the mental health counselor can educate the parent about normal sexual development in young girls, and its characteristics of curiosity and playfulness being different than the adult qualities of passion and eroticism. The mother can certainly set limits on her child's behavior; however, understanding the childhood development may enable the parent to have realistic expectations and apply realistic consequences for the child if the limits are crossed.

When treating children with sexual behavior problems, mental health counselors may miss some treatable problem areas if they assume that only direct sexual abuse would result in problematic sexual behaviors. Mental health counselors may be able to assist some families in understanding that exposure to sexual language, material, and behaviors can have detrimental effects on a child. When parents become aware of the effects of certain influences, they can sometimes remove the factors that contribute to the child's sexual behavior problems. For instance, a couple living in a one-room apartment chose to have their child share a bed with them. Although the parents believed that the 4-year-old child was asleep before they ever engaged in sexual activity, the little girl ceased her excessive masturbation and sexual sounds when she was given her own private area to sleep that was separated from her parents' bed by a curtain (Johnson, 1999).

When faced with the situation of a child who is exhibiting a sexual fascination with a particular parent, mental health counselors can assist parents in continuing to respond to their child's affection in a positive and loving manner while gently setting limits on the child's behavior. For example, if a 5-year-old male rubs his mother's breast, his mother can say, "I prefer that you not touch my breast. You can give me a hug like this (modeling appropriate hugging) when you want to touch me." Handled in this manner, the child will eventually come to understand that although the parent is affectionate, the relationship will not become sexual; and the child can continue with his or her sexual development (Mrazek & Mrazek, 1987). In addition, mental health counselors can help parents to model appropriate and careful handling of other people's bodies and to set acceptable limits for physical interaction for their children. In some cases, education for the parents on how to handle the child's "inappropriate" behavior can prevent sexually abusive relationships from beginning, though there is no implication that sexual abuse could be caused by a child.

Behaviors that continue in spite of clear and consistent requests for the child to stop them are indicative of a problem (Johnson, 1999). Sometimes children with sexual behavior problems are unable to stop themselves from performing the behaviors. This persistence can represent a compulsion (Asher, 1988), or it may be indicative of the child dissociating and performing the behaviors without being fully aware of them (Johnson; Walker & Bolkovatz, 1988). Dissociation, the ability to separate mind and body to modify the experience of pain (Friedrich et al., 1997), is a common defense mechanism used by children that have been sexually, physically, and/or emotionally abused (Walker & Bolkovatz). Children are sometimes conscious of their ability to dissociate in stressful situations. Walker and Bolkovatz suggest having the child express feelings that originated during the trauma incidents, employing play materials, to enable the child to discontinue this extreme reaction to anxiety. Mental health counselors can help parents understand their child's dissociating behaviors (e.g., staring blankly, forgetfulness, sudden shifts in mood or behavior) by explaining that dissociation is a coping/survival skill that the child has needed in the past. Framed positively, this knowledge may help the parents to be patient with any sexual behaviors that may occur as the child works through the process of decreasing dissociation and making the defense no longer necessary.

Seductive behaviors in children are an important issue for the mental health counselor to address in counseling (Walker & Bolkovatz, 1988). Children that have been sexually abused have often learned social norms that involve sexualized behavior when interacting with others. They may have learned that seductive behaviors lead to affection and love. These children's learned seductive behaviors can readily lead to their revictimization if not addressed and diminished (Spencer & Nicholson, 1988). When working to reduce a child's seductive behaviors, mental health counselors need to be accepting of the child's feelings, including the possible enjoyment of sexual stimulation, while teaching appropriate behaviors and stressing consequences (Walker & Bolkovatz).

CONCLUSION

There are few studies assessing the normal sexual behaviors of non-clinical preadolescent children, and additional research is needed. Moreover, there is even less theory and research examining the effect of cultural differences on normal sexual behaviors in preadolescent children. Further research is needed in this area as well. Mental health counselors should be cautious in generalizing the characteristics of normalcy for preadolescent child sexual behaviors to immigrant or non-majority populations. Researchers have found that sexual behaviors that are rare in American children (i.e., inserts objects into vagina/anus, asks to engage in sexual acts) are also rare in children of other cultures (Friedrich et al., 2000), and it is important to note that there is no single child sexual behavior that has been exclusively linked to child sexual abuse (Johnson, 1999). With the data available, researchers have assumed that these rarely occurring behaviors can occur in non-sexually abused children due to individual differences and circumstances. However, researchers have relied on parental report to determine whether a child has been sexually abused. There is a chance, therefore, that children with unknown abuse have participated in the studies used to determine normal sexual behaviors.

Mental health counselors are expected to have expertise regarding what constitutes normal and abnormal sexual behavior in children. With the current focus on child sexual abuse and the established relationship between abuse and sexual acting out, mental health counselors have cause for concern over the topic and need to be aware of what behaviors are normal in order to determine problem areas. Once these problem areas are addressed, children can learn to behave in sexually appropriate ways.

REFERENCES

Asher, S. J. (1988). The effects of childhood sexual abuse: A review of the issues and evidence. In L. E. Walker (Ed.), Handbook on sexual abuse of children: Assessment and treatment issues (pp. 3-18). New York, NY: Springer.

Beitchman, J., Zucker, K., Hood, J., DaCosta, G., & Akman, D. (1991). A review of the short-term effects of child sexual abuse. Child Abuse and Neglect, 15, 537-556.

Browne, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the research. Psychological Bulletin, 99, 66-77.

Friedrich, W. N. (1993). Sexual victimization and sexual behavior in children: A review of the recent literature. Child Abuse and Neglect, 17, 59-66.

Friedrich, W. N., Fisher, J., Dittner, C., Acton, R., Berliner, L., Butler, J., et al. (2001). Child sexual behavior inventory: Normative, psychiatric, and sexual abuse comparisons. Child Maltreatment, 6(1), 37-49.

Friedrich, W. N., & Grambsch, R (1992). Child sexual behavior inventory: Normative and clinical comparisons. Psychological Assessment, 4, 303-311.

Friedrich, W. N., Grambsch, P., Broughton, D., Kuiper, J., & Beilke, R. (1991). Normative sexual behavior in children. Pediatrics, 88, 456-464.

Friedrich, W. N., Jaworski, T. M., Huxsahl, J. E., & Bengtson, B. S. (1997). Dissociative and sexual behaviors in children and adolescents with sexual abuse and psychiatric histories. Journal of Interpersonal Violence, 12, 155-171.

Friedrich, W. N., Sandfort, T., Oostveen, J., & Cohen-Kettenis, P. (2000). Cultural differences in sexual behavior: 2-6 year old Dutch and American children. In T. Sandfort & J. Rademakers (Eds.), Childhood sexuality (pp. 117-129). New York: Haworth.

Hibbard, R., Roughmann, K., Hoekelman, R. (1987). Genitalia in children's drawings: An association with sexual abuse. Pediatrics, 79, 129-137.

Johnson, T. C. (1999). Understanding your child's sexual behavior: What's natural and healthy. New York: New Harbinger.

Kendall-Tackett, K., Williams, L., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113, 164-180.

Koocher, G., White, C., Sivan, A., Goodman, G., Friedrich, W. N., & Reynolds, C. (1995). Psychological science and the use of anatomically detailed dolls in child sexual abuse assessments. Psychological Bulletin, 118, 199-222.

Larsson, I., & Svedin, L. (2002). Teachers' and parents' reports on 3-to 6-year-old children's sexual behavior: A comparison. Child Abuse and Neglect, 26, 247-266.

Mrazek, D., & Mrazek, P. (1987). Psychosexual development within the family. In P. Mrazek & C. Kempe (Eds.), Sexually abused children and their families (pp. 17-32). New York: Pergamon Press.

McClellan, J., McCurry, C., Ronnei, M., Adams, J., Eisner, A., & Storck, M. (1996). Age of onset of sexual abuse: Relationship to sexually inappropriate behaviors. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1375-1383.

National Child Abuse Hotline. (December, 2002). Retrieved October 19, 2003, from http://www.nal.usda.gov/pavnet/pm/pmnatchh.htm

O'Malley, S. (2002). At all costs: Mandatory child abuse reporting statutes and the clergy-communicant privilege. Review of Litigation, 21, 701-726.

Piaget, J. (1997). The moral judgment of the child (Gabain, M., Trans.). New York: Free Press Paperbacks. (Original work published 1965)

Rademakers, J., Laan, M., & Straver, C. (2000). Studying children's sexuality from the child's perspective. In T. Sandfort & J. Rademakers (Eds.), Childhood sexuality (pp. 49-61). New York: Haworth.

Rothbaum, F., Grauer, A., & Rubin, D. (1997). Becoming sexual: Differences between child and adult sexuality. Young Children, 52(6), 22-28.

Schuhrke, 13. (2000). Young children's curiosity about other people's genitals. In T. Sandfort & J. Rademakers (Eds.), Childhood sexuality (pp. 117-129). New York: Haworth.

Spencer, C. C., & Nicholson, M. A. (1988). Incest investigation and treatment planning by child protective services. In L. E. Walker (Ed.), Handbook on sexual abuse of children: Assessment and treatment issues (pp. 152-174). New York: Springer.

Walker, L. E., & Bolkovatz, M. A. (1988). Play therapy with children who have experienced sexual assault. In L. E. Walker (Ed.), Handbook on sexual abuse of children: Assessment and treatment issues (pp. 249-269). New York: Springer.

Page L. Thanasiu is a doctoral candidate in Counselor Education, University of Central Florida, Orlando. E-mail: [e-mail]