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DSM III and Psychosocial disorder in childhood.

The Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), divides psychosexual disorders into four groups. Gender identity disorders are characterized by the individual's feelings of discomfort with an inappropriateness about his or her anatomic sex and by persistent behaviors generally associated with the other sex. Paraphilias are characterized by arousal in response to sexual objects or situations that are not part of normative arousal activity patterns and that, in varying degrees, may interfere with the capacity for reciprocal affectionate sexual activity. Psychosexual dysfunctions are characterized by inhibitions in sexual desire or the psychophysiological changes that characterize the sexual response cycle. Finally, there is a residual class of other psychosexual disorders that has two categories: ego dystonic homosexuality and psychosexual disorders not elsewhere classified.

The only category specifically related to children is 302.60, Gender Identity Disorder of Childhood

The diagnostic criteria for this category for females is:

A. Strongly and persistently stated desire to be a boy or insistence that she is a boy (not merely a desire for any perceived cultural advantages from being a boy).

B. Persistent repudiation of female anatomic structures, as manifested by at least one of the following repeated assertions:

1. That she will grow up to become a man (not merely in role).

2. That she is biologically unable to become pregnant.

3. That she will not develop breasts.

4. That she has no vagina.

5. That she has or will grow a penis.

C. Onset of the disturbance before puberty.

The diagnostic criteria for males:

A. Strongly and persistently stated desire to be a girl or insistence that he is a girl.

B. Either one or two.

1. Persistent repudiation of male anatomic structures as manifested by at least one of the following repeated assertions:

a. That he will grow up to become a woman (not merely in role).

b. That his penis or testes are disgusting or will disappear.

c. That it would be better not to have a penis or testes.

2. Preoccupation with female stereotypical activities, as manifested by a preference for either cross-dressing or simulating female attire or by a compelling desire to participate in the games and pastimes of girls.

C. Onset of the disturbance before puberty.


The essential feature of disorders in this sub-class is that unusual or bizarre imagery or acts are necessary for sexual excitement. Such imagery or acts tend to be insistently and involuntarily repetitive and generally involve either 1) preference for use of a non human object for sexual arousal, 2) repetitive sexual activity with humans involving real or simulated suffering or humiliation or 3) repetitive sexual activity with non consenting partners. Since paraphilic imagery is necessary for erotic arousal, it must be included in masturbatory or coital fantasies if not actually acted out. In the absence of paraphilic imagery, there is no relief from erotic tension; and sexual excitement and/or orgasm is not attained. The imagery in a paraphilic fantasy (rape, S&M, bestiality, etc.) or the object of sexual excitement in a paraphilia is frequently the stimulus for sexual excitement in individuals without psychosexual disorder. Paraphilic imagery or the use of objects would be considered normative in childhood masturbation sexual patterns because of children's limited sexual knowledge and options. In that regard, fetish behavior is not included as a diagnosis in childhood. Before the onset of post pubescent partner sex, the criteria of "repeatedly preferred" (to partner sex) is not assessable; and when masturbation is the only sanctioned or available sexual option, the use of inanimate objects to enhance the experience is common. When other options (partners) are sanctioned and available, the "exclusive or consistently preferred" use of inanimate objects is considered a fetish.

Although the age of onset for fetishes is in childhood or adolescence, paraphilic attachments of childhood and adolescence may recede in their importance or degree of dependency when other sexual options become available. For example, the panty fetish (one of the most common) may begin in childhood as a young boy stimulates himself with thoughts of, procurement of and masturbation with or into female panties. However, the adult obsession with collecting panties for sexual use, accompanied by diminished erotic response to partner sex, is not necessarily the eventual result of this early childhood fixation. The adult transition to gratifying partner sex may be smooth and uncomplicated, with childhood sexual patterns giving way to appropriate adult patterns as increasingly varied sexual options and opportunities become available. The adult male's interest in panties as a sexual stimulant may remain, but may become less important in the overall adult sex pattern. Fantasies about panties as a part of sexual arousal and/or masturbation, the purchase of panties as a personal gift to the partner, requesting the partner to wear panties as a part of sexual foreplay, etc., may not be considered a fetish because it is not the consistently preferred, necessary or exclusive sexual pattern.

Sometimes a young boy's erotization of panties leads him to public behavior that is socially unacceptable. Stealing panties from family members or from clotheslines and peeping, especially in the windows of neighbors, may bring a child to the attention of the police or mental health professionals; and treatment is required. The behavior is asocial and may be obsessive, but the diagnosis of fetishism is still premature: This and other asocial behavior such as public exposing of genitalia, may or may not be accompanied by a mental disorder; and a differential diagnosis is imperative. Given the contradictory and confusing way that Western culture handles sexual development, it is erroneous to assume that asocial sexual acts of children are vis-a-vis characterological pathology.

Psychosexual Dysfunctions

Psychosexual dysfunctions, characterized by inhibitions in sexual desire or the physiological changes that characterize the sexual response cycle, are undiagnosable in children, although there is reason to assume that they may be manifest. There is no help for children who have developmental sexual problems (e.g., arousal, orgasm, pain, guilt, low sensation, etc.). Lack of knowledge and misunderstanding is a major problem, and most children and adolescents worry about being normal. What is still lacking in any shape or form in childhood is an open discussion about sexual anxieties, sexual expectations, different sexual acts and feelings about sex. In one study, 33% of girls (14-18) were not sure if they had an orgasm because they had no idea what it was supposed to feel like. Most post pubescent adolescents masturbate, but the majority feel guilty, ashamed, dirty, stupid, embarrassed or abnormal after the act (Hass, 1979).

Although are no studies on sexual dysfunction in childhood, retrospective sex histories of adults and case histories of children in psychotherapy suggest that all is not well. We have underestimated the significance of sexual interactions and fantasies in childhood. Until we better understand the development of the erotic response through childhood and adolescence and until normative behavior gradients are established, children's sexual needs will not be properly addressed by the mental health community.

Ego Dystonic Homosexuality

Undesired homosexuality is undiagnosable in childhood. Although many adult homosexuals retrospectively identify indications of their adult orientation in childhood events, same-sex experimentation in childhood is a common experience in the sex histories of heterosexual adults. It is well to remember that homosexuality is a behavior which is dependent on the preference of same-sex partners. The adolescent discovers and defines the elements of sexual attraction, unique and individual to him/herself as an ongoing process of differentiation. The homosexual discovers that s/he is sexually excited by same-sex stimuli in the same way that the heterosexual discovers that s/he is excited by opposite sex stimuli; and within these categories, they both discover even more specific attractants (e.g., body types, body parts, sex acts, positions, odors, words, etc.). It is possible for a homophobic adolescent to be disgusted with his or her feelings of attraction to same-sex peers and to fear the consequences of a Gay life; however, ego dystonic homosexuality would rarely be diagnosed before early adulthood. We have come to understand that even the most serious love affair with a same-sex partner may not be generalized to an ongoing same-sex attraction; thus, adolescence is too early to make a definitive diagnosis. The lack of child sex syndromes described in DSM III does not mean that children and adolescents are free from sexual problems or that clinicians are not consulted about the sexual behaviors of children and adolescents. Sexual problems of children, as seen on an out-patient basis by mental or physical health care professionals, are usually public or semi-public behaviors that cause adults (usually the parent) embarrassment and concern because they are a departure from society's expectations. There are many sexual events and/or behaviors that cause children to be referred for psychological evaluation. The parents' decision to seek professional consultation is the solution to their feelings of worry that the child is not normal, fear that if they don't intervene, the child will grow up to be a sexually deviant adult, doubt that they have the knowledge or skill to change the behavior pattern and guilt that they have caused or contributed to the undesirable behavior.

Gender Identity Disorder in Children with Normal Genitalia

Gender Identity Disorder (GID) is a persistent belief that one's gender has been wrongly assigned and a persistent repudiation of one's assigned anatomical gender. In children, it is often confused with homosexuality; and parents seek diagnosis and treatment for their child in response to symptoms of opposite sex mannerisms and behavior. Their concerns include embarrassment to the family members, stigmatizing of the child and potential homosexuality. Actually, the adult manifestation of GID is transsexualism, expressed as the feeling of being trapped in the body of the opposite sex.

Gender Behavior Disorder

Gender behavior disorder in children (mostly males) is characterized by cross gender or androgynous behavior that is learned and reinforced by the environment rather than being linked to a persistent belief that they are, in fact, the other sex. The adult manifestation of GBD is transvestism and effeminate behavior. It is important to differentiate GID from GBD in the diagnostic process. The child who believes s/he is wrongly assigned suffers from chronic and severe cognitive dissonance, whereas children who know their anatomical gender but who enjoy androgynous behavior will suffer only if the environment is punitive and non supportive. Sexual reassignment of children is considered only in cases of gender dysphoria or non-specific amorphous genital structure. A GID adult with normal genitalia might request gender reassignment surgery as a matter of choice.

Excessive or Compulsive Masturbation

Masturbation frequency is highly variable in an individual child, as well as between children. Although normative frequency data for specific ages is unavailable, children are often referred to clinicians for excessive or compulsive masturbation. This is a subjective quantification taken to mean that the child is preoccupied with masturbatory activity to the exclusion of other age appropriate pursuits and/or that the scope of the masturbation activity is resulting in stigmatizing censure from others that may create secondary adjustment problems for the child.

Sexologists believe that masturbation is a viable sexual activity throughout the life span and that it need not be considered a poor post pubescent substitute for sex with a partner. Research in female sexuality (Hite, 1976) and the treatment of anorgasmia in adult women (Barbach, 1975; Chapman, 1977; Dodson, 1974) suggest that masturbation to orgasm is an important developmental step and possibly, a prerequisite to becoming reliably orgasmic in adult partner sex. It is often a treatment of choice for male and female sexual dysfunction (Kaplan, 1979) and is reported as a childhood activity of some importance by most adults (Hass, 1979; Hite, 1976, 1978; Kinsey, 1948, 1953).

Sexologists suggest that young boys be encouraged to prolong the arousal stage of their masturbation so as not to condition a rapid stimulus response bond between erection and ejaculation. Young girls should be encouraged to look at and identify their external genitalia and to connect their erotic feelings and sexual response cycle to appropriate genital body parts along with others they might already have. Parents need to understand that childhood masturbation is a normal and beneficial behavior that needs to be managed to coincide with social etiquette.

Precocious Sexual Interest and Behavior

Clinicians are often consulted by parents who are anxious about their child's interest in sexual topics, masturbation or sex play with siblings and peers. If the child's basic interest in sex is complimented by unsupervised opportunity to engage in trial-and-error learning with a partner, sexual rehearsal play is predictable. Some sexologists suggest that not only is sexual rehearsal play quite predictable in children, it is advisable and should be encouraged in order to forestall adult sexual problems (Money, 1975; Yates, 1978).

Intense and continued or intermittent sexual interest in children should be accommodated as any other interest would be. Age appropriate books and conversations with parents endorse the child's curiosity about this important part of life and encourage an open and unashamed quest for sexual knowledge. In contrast, a child who shows little interest or curiosity about sex should not be overwhelmed with sex information by over-zealous parents. Some children personalize their sexuality very early and are uncomfortable with candid sex conversations. They appreciate appropriate sex materials to be used in private and occasional one-on-one talks with a parent to clear up any troublesome sexual ideas or feelings. A few parents may worry about a child with low sex interest, but lack of sex interest is more often considered normal in children. Of greater concern is the child who is very public with sex talk and sex play, masturbation with self or with peers. Parents are concerned that the child is abnormal genetically or hormonally, that s/he will be censured by other adults and children, that his/her sexual behavior will reflect badly on siblings and family, that s/he will be a target for sexual abuse or exploitation by adults or that s/he will grow up to be promiscuous or perverted.

Three-year old D was a highly sexed boy who had been involved in sex play with age mates and an older child. He asked his therapist if she wanted to put her mouth on his "dinky." When she replied in the negative, he pleaded "you'll like it," "I'll pay you money," "I'll be your best friend." When asked if he liked to "play dinky," he frowned menacingly, clenched his fists and aggressively replied, "yes, I like it, and I'm not going to stop!"

Children who are pseudo-mature in any sense are special children with special needs. They demand more from parents and may be considered a blessing or a curse, depending on the value system and resources of the parents. Intellectual genius, superior athletic potential and exceptional musical talent are all considered valuable gifts that should not be wasted. The child who is sexually precocious in development or interest is, in contrast, shunned and pitied. The parents of these children need help, not only in the management of the child's behavior, but also in considering that precocity in this area need not be thought of as an affliction.

Children Who Report Sexual Contact with an Adult Which Cannot Be Substantiated

Psychological literature and the popular press report and often sensationalize the plight of the traumatized child whose story of sexual activity with an adult is not believed and, conversely, of the victimized adult who steadfastly denies the sexual accusations of a child. The most commonly reported pedophilic situation is that of the adult male and the prepubescent female. This is not to say that sex between an adult female and a prepubescent male does not occur, but it would probably not be reported; and if it were, it would probably not be considered a traumatic experience for the child.

In Western culture, there is a time-honored tradition of young boys being sexually initiated by an experienced older woman. Girls, in contrast, are considered permanently damaged by early sexual initiation by an adult male. The society's attitude that the child has been damaged by a sexual experience is extended to boys only if the sexual encounter is homosexual or if residual physical damage is sustained. Sexual behavior between an adult female and a female child is the least reported pedophilic possibility and is of least interest to law enforcement and the community at large.

It is difficult to generalize about adult/child sex because of the variability of age and sex in any individual case. It is important to note that if the sexual encounter occurred and if it was traumatic for the child, the diagnostic process with a clinical child sexologist is therapeutic. Psychotherapy consists of talking about traumatic situations in order to bring the experience into cognitive awareness and to work through the feelings engendered by the event. Properly handled, a sexual trauma is no exception to this process. A client is ill served by a therapist who feels that the child has been permanently damaged by the experience and relates to him/her as a victim.

Many adult women have reported satisfying non traumatic prepubescent incestuous relationships from which they graduated to post pubescent sex with peers without undue incident. In contrast, many patients in psychotherapy report unresolved conflicts in association with childhood sexual experiences; and there is some evidence to suggest that the greater the age differential between participants, the greater the potential for trauma. It is important to note that most reported pedophilic sex is incestuous and that incest is a family rather than an individual pathology.

Post-pubescent Sex with a Partner, Heterosexual

Sexologists have attempted to deal with the question of sexual readiness in terms of chronological age; and there is a reasonable consensus that around the age of 16, adolescents are physiologically and psychologically ready. The older adolescent is interested in forming primary relationships outside the nuclear family, and sexual sharing is an integral part of these relationships.

Sexuality is a major concern of adolescence; and in that regard, adolescents are poorly served by the professional community, the family, the school and the culture (Hass, 1979).

The professional mental health worker sees a small fraction of adolescents and may or may not address sexual issues. Family members have little credibility in sexuality if the foundation was not accomplished in childhood. The school is still concentrating on reproductive biology and venereal disease, while the adolescent needs help with socio-sexual issues. The culture simultaneously stimulates and misinforms, encourages and prohibits, punishes and rewards the adolescent for sexual interest and behavior.

The revered notion that sex is natural, happening with style, sensitivity and spirituality when two people love each other, is a myth that significantly departs from most reported first encounters. It does however, perpetuate a rationale for those who oppose real sex education and dooms the teenager who is misinformed by the exploitive messages of the marketplace.

Post-pubescent Sex with a Partner, Homosexual

Increasingly, counselors and therapists are consulted when parents suspect or know that their adolescent is in love with a person of the same sex. Even though societal attitudes are relaxing and homosexuality is no longer a disease category in the APA DSM-III, for the individual family, it is a major trauma. Professional consultation is sought by the parent with the initial purpose of curing the errant behavior, but the family system is the actual patient or client. Both parents and child need to know that a same-sex love affair does not automatically mean that either participant has a homosexual orientation or that a heterosexual love affair guarantees a heterosexual orientation. It may be that the love object happens to be of the same sex, but the love feelings are unique to that individual and may not be generalized to others of the same sex. Perhaps a bisexual resolution will occur, with either or both sexes being available as primary partners throughout a specific life phase or across the life span. Additionally, the first same-sex love may be the expression of an exclusively homosexual life pattern to come. It is well to keep in mind that the child is doing what comes naturally. Children experience their erotic and love feelings in association with certain people and events and not in association with other people and events.

Occasionally, an adolescent will seek consultation about homosexual feelings or experiences without parental knowledge. A few adolescents are totally unaccepting of homosexuality and are repulsed by any same-sex attraction they might feel. They are traumatized by a same-sex approach or experience, even though they may have been a willing participant. They seek professional help to get rid of whatever is causing their attraction to and by members of the same sex.

Most parents fervently hope that their child's same-sex preference is a phase they are passing through, and they are unwilling to disown their homosexual child. Some families or individual family members may be unwilling or incapable of accepting homosexuality, thus precipitating the Gay adolescent's premature emancipation from family.

Sexual Concerns of the Physically and Mentally Disabled

The myth of the sexual innocence of childhood is most secure in the homes of the disabled child. Close parental supervision, limited autonomy with peers, identity as a physically disabled child or child with special needs and rejection by peers as a potential sex partner all contribute to the negation of sexuality of the physically or mentally disabled child. Disabled children have sexual curiosity and sexual feelings. Despite the conspiracy of silence, they need basic sexual knowledge and information regarding how they can be sexual, given their specific limitations. As adolescents, they need opportunities to experience their sexual response cycle, to learn what their individual sexual limitations and abilities are and perhaps, more importantly, how to negotiate for sex with a partner, especially the orthopedically handicapped, who are assumed to be incapable of being sexual by most non disabled people.

A physically healthy child with mental retardation poses another type of problem. They may be quite normal in physical and sexual development and as an adolescent, may be attractive enough to be selected as a potential sex partner by a peer or an adult. Impaired mental function may, however, disallow good judgment in sexual situations. Their own sexual desire, coupled with this lack of discrimination, makes them an easy target for sexual exploitation. The mentally retarded child needs explicit sex education; reinforced, plainly stated rules about socio-sexual conduct; adequate supervision and effective birth control at the appropriate age.

Families of disabled adolescents who live at home and caretakers of institutionalized teens, need to facilitate the sexual opportunities of their charges. Even if s/he can acquire potential partners, the disabled adolescent needs a safe place, privacy and, perhaps, some physical assistance to have a successful sexual experience. The issues of birth control and paid partners are complicated for adolescents or young adults in institutions or on public assistance, as charges for these services are not reimbursable by third party payers. As a society, by default, we have decided that the disabled shall not have sex lives. The advocacy groups for individuals with special needs have not provided or demanded sexual equality and sexual rights, which, for many disabled people, are as important as access to public buildings or the Special Olympics.

Sexual Guilt as a Factor in the Treatment of the Hospitalized Child

Psychological services for the child hospitalized on the medical or surgical ward have become standard practice in many hospitals. In both routine ward service and psychological referrals, the alleviation of sexual guilt with regard to masturbation is often a significant factor in the understanding and treatment of the physical illness. From the concrete thinking of the young child to the maturing moralism of the teenager, the cause-and-effect rationale is predominant. The simplistic link from bad thoughts to bad deeds usually includes the forbidden sexual behaviors. A frank discussion about masturbation, what it is and what it isn't, allows the therapist to assuage the child's guilt about masturbation, to demythologize and disconnect sexual behavior as the cause of the injury or illness, to impart accurate information and to give permission for continued masturbatory behavior in the hospital, helps to facilitate trust in the therapist about these personal concerns and others (e.g., recovery, abandonment, death, etc.).

Most adults are ambivalent about children's masturbation. Medical and hospital personnel may need some help in understanding the purpose of dealing with masturbation when health concerns are primary. Masturbation is an effective tension- and anxiety reducer in children and adults, and it is self affirming. It is an activity that reclaims the body and offsets intrusive hospital procedures. The cessation of a regular masturbation pattern constitutes an unnecessary deprivation and added stress to an already stressful situation.

Child Prostitution and Kiddie Porn

The exploitation of children is an anathema in our humanitarian society. We have laws to protect children from unscrupulous adults; however, there is a societal reluctance to intrude on the autonomy of the nuclear family. The campaign for the recognition of the battered child as a syndrome of ongoing abuse was hard-fought in the 1960s. No one wanted to believe or admit that it was a widespread phenomenon that had crossed all educational, socioeconomic, racial, ethnic and religious lines.

Child prostitution and kiddie porn are similarly societal problems that adults are trying hard not to address. Runaways who become street children, with no jobs (many are too young to work legally), no money, no shelter, etc., quickly learn that they have only one negotiable commodity--their sexuality. Male or female, they can sell their bodies to adult men. Although the ranks of street children relegated to prostitution and other forms of sexual exploitation grow consistently, some children are encouraged by a parent into prostitution to augment the family income and upgrade the standard of living of mother and siblings. These children are usually female, living with a mother as a single parent. Girls in this situation are more apt to come to the attention of authorities and be referred for evaluation and therapy than street children, who are rarely seen professionally. Any individual can be psychologically evaluated and can benefit from the self-knowledge gained in psychotherapy; however, child prostitution and kiddie porn are broad spectrum societal problems that will not be alleviated by individual psychotherapy.

Other Symptoms of Sexual Significance

Peeping Toms, stealing underwear and sex with animals are asocial and illegal activities which may be transient attempts to satisfy child or adolescent sexual curiosity, or they may be the development of aberrant patterns of voyeurism, fetishism and bestiality. The behavior may be in response to a lack of knowledge or an expression of underlying psychopathology. It is helpful to the child if the differential diagnosis is made by a therapist who doesn't over-react to the symptoms. It is well to remember that society's messages about sex are contradictory and confusing to children and adolescents. Whether the resultant dissonance is expressed as private worry, fear and doubt or erupts into public behavior, children are well served by accurate information, endorsement of the normalcy of sexual feelings and desires, their right to be sexual and an opportunity to learn culturally acceptable socio-sexual behavior and skills.


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Spitz, Rene A. (1952). Authority & Masturbation: Some remarks on a bibliographical investigation. Psychoanalytic Quarterly, 21, 490-527.

Yates, Alayne (1978). Sex Without Shame: Encouraging the Child's Healthy Sexual Development. NY, NY: William Morrow & Co.
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Publication:Electronic Journal of Human Sexuality
Date:Jan 1, 2000
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