This article was published in CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA, 13(3): 569-589, © 2004 Elsevier Inc. and is posted with permission of Elsevier Inc. Access to the published article can be obtained via http://www.ScienceDirect.com.

 

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Situating Unusual Child and Adolescent Sexual Behavior in Context

 

                                                      Charles Moser, PhD, MD,a

                                                      Peggy J. Kleinplatz, PhD,b

                                                      Dino Zuccarini BA,b  and

                                                      William G. Reiner, MDc

 
         aInstitute for Advanced Study of Human Sexuality and Private Practice, Sexual Medicine and Internal
            Medicine, San Francisco, CA 94109 USA docx2@ix.netcom.com
         
            bSchool of Psychology, University of Ottawa, Ottawa, Ontario, Canada
 

            cDepartment of Urology, Division of Pediatric Urology, and Dept. of Psychiatry,  Child and Adolescent

         Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA

 

Abstract

There is a lack of scientific knowledge concerning what constitutes normal versus unusual sexual behaviors among minors. Clinical judgements in these cases are often clouded by unfounded socio-cultural assumptions, personal biases, legal issues, and moral considerations.  Current diagnostic nomenclature commonly used for adult sexual activities is inappropriately applied to minors.  Considerations about unusual sexual interests (i.e., frequency of sexual behaviors, difficulties controlling sexual expression, consent, non-heterosexual interests, much older or younger partners, atypical sexual stimuli, number of partners and sexual abuse) are explored to provide perspective for evaluation.    

 

Situating Unusual Child and Adolescent Sexual Behavior in Context

         R Generally, review articles are intended to guide and update clinicians.  When we accepted this task, we knew that the existing data about unusual childhood sexual behaviors were minimal and that most of the common beliefs in this area were based upon preconceived notions.  We performed an extensive literature search but the lack of evidence for even the most basic information was still surprising.  Although some literature exists about conventional sexual behaviors (e.g., heterosexual coitus, masturbation), unusual interests have been ignored for the most part in children and adolescents. There has been voluminous attention to youthful sex offenders, though this represents a legal category rather than a clinical population, and epidemiological data even here is largely absent. The literature focuses almost exclusively on young males, with a dearth of attention to unusual sexual behavior in females.     

         Parents routinely ask clinicians about the sexual activities of their children and adolescents.  Most of these concerns are dealt with easily, appropriately or otherwise, and the activities deemed to be part of normal sexual development. A few unusual sexual concerns are referred for further assessment, diagnosis, and treatment.  Existing scientific theory – actually hypotheses – are short on empirical data.  It is difficult to discern what is unusual if one does not know what is usual.  It is not clear which unusual behaviors are signs of future problems and which are just uncommon.   Treatment of these individuals without data on the effectiveness of different modalities can be risky; follow-up studies are also lacking.  Our best advice is to “First, do no harm” and re-evaluate methods frequently. Children are not little adults; evaluation and treatment techniques for adults in general should not be generalized to children.  Children and adolescents who present with unusual sexual behaviors provide practitioners with complex assessment, diagnosis and treatment challenges.

         The inability to define unusual sexual behavior clearly has made our task much more difficult.  For example, someone who is more interested in sexuality than the one making the judgment might be called sexually obsessed.  Similarly, in comparison to the evaluator, masturbating more is seen as excessive, having more partners is characterized as promiscuous, and having more frequent sex is regarded as nymphomania or satyriasis.  Having a sexual interest different from the evaluator usually connotes that the interest is unusual, if not pathologic. About 100 years ago, physicians treated “hysteria” in women by masturbating them to “paroxysmal convulsions” (ie, orgasm) (1) while also warning of serious health risks from masturbation (2). Unfortunately, our understanding of developmental sexuality has not changed greatly since that era. It is important to proceed carefully and not allow the current moral climate to influence unduly the clinical interpretation of unusual sexual behaviors.     

         In our experience, adolescents rarely request help for unusual sexual concerns to their caregivers: They "understand" that sex is not a discussion topic.  It is the caregiver who becomes concerned and seeks further evaluation.  Parents or school authorities who are worried about the appropriateness of particular sexual behaviors usually refer these patients, but only after attempts to exert control have failed.  Courts also refer adolescents for a wide range of sexual offenses, some of which would constitute serious crimes if committed by an adult and some of which would be ignored if committed by an adult.  Practitioners are asked to assess the nature and scope of the behaviors in question, to determine whether they are pathological and require diagnostic classification, are problematic but non-pathological, or are stage-appropriate sexual behaviors. Practitioners must evaluate what is ‘normal’ and what is ‘abnormal’ sexual behavior.  This endeavor is complicated in a society that shows minimal concern about television violence for children, for example, but may overreact to nudity or depictions of nonheterosexual behaviors.  

         The purpose of this paper is to place the sexual interests and behaviors of children and adolescents into context; the focus is on actual behavior rather than fantasy.  Focusing interventions on fantasies would probably create considerable clinical difficulty.  The emphasis will be on post-pubescent minors.  We hope to provide practitioners with an approach to understanding these acts within the larger developmental processes.  Because of the enormity of our task, we do not discuss children or adolescents who display unusual forms of gender expression, gender nonconformity, or report gender dysphoria.

 

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.  Prior to this change, adolescents were treated as adults by society (3). 

         For most of human history, children participated in adult social and economic life and shared single-room homes that exposed them to adult sexual conversations and behaviors. Within this context, the prevalent expectation was that adolescents were to be sexual and reproductive from an early age. By the late sixteenth century, the meaning of childhood and adolescence had shifted.  Childhood was construed as a particular stage with developmental priorities related to sexuality.  Children were perceived to be fragile, weak creatures that needed protection from the vicissitudes of adult sexuality. The romantic conception of the “innocent” and “asexual” child requiring protection from adult sexuality blossomed during the Victorian era. The notion grew that masturbation caused insanity and that it was necessary to suppress sexual appetites. Previously, sexual restrictions were justified on moral and religious grounds; however, during the Victorian era medical rationales for sexual suppression began to predominate. Public concern about the sexual habits of children and adolescents became significant to society and were scrutinized increasingly by parents, and religious, medical and legal authorities (3). The meanings that were ascribed to child and adolescent sexual development and behavior during this period continue to inform our beliefs about children as sexually ‘innocent’ and adolescence as a period that requires sexual constraint. 

         Since the beginning of the twentieth century, the meaning of childhood and adolescent sexuality has remained highly contested (4).  Children and adolescents must sift through mixed messages about sexuality and sexual behavior as both dangerous and pleasurable.  Children are told that sexuality is dangerous and predominantly linked to social problems, teenage pregnancy and sexually transmitted infections (STIs); conversely, they are told that sexuality is a source of personal fulfillment and pleasure.  Clinical wisdom about psychosexual development must be situated in this historical context and  recognize that what constitutes acceptable sexual expression among children may be influenced by political, social, and moral prerogatives or romanticized by the notion of childhood “innocence”.

 

The sex 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 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 conditions may have sexual ramifications.  Any clinician, therefore, must find perspective in a given child’s unusual sexual behaviors or reactions to any social as well as clinical circumstances.  Apparent absence of sexual interest or muted sexual behaviors are atypical.  Intense sexual behaviors may be associated with co-morbid conditions (eg, disruptive disorders) or primary psychiatric illness; these conditions must be entertained and require assessment and intervention targeting the sexual behaviors.  These conditions are beyond the scope of this discussion.

         Additionally, most parents as well as clinical professionals are poorly versed in typical psychosexual development in children - at least until experience intervenes and possibly educates.  Thus, perspective is important; sexual behaviors may be unusual in one circumstance and fairly typical in others.  Alleviating the anxieties of parents or other adults may be a significant goal of clinical interventions.  Additional goals of interventions for unusual sexual behaviors, however, must include prevention of dangerous behaviors, mitigation of family concerns or conflicts regarding sexual behaviors, encouragement of healthy psychosexual development, and alleviation of child anxieties about sexual feelings, fantasies, or expression.

 

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 will eventually lead towards 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 people believe that even mentioning sexual options or allowing for any sexual activity will encourage sexual experimentation (5).

         There is little appreciation that sexuality can potentiate positive experiences in the lives of teenagers and even less is done to make sex growth-affirming for them.  Young boys may be made to feel ashamed of their ease in getting erections. Young girls may learn to feel that their sexual desires are dangerous and must be constrained (6). Sex counseling and therapy are rarely even contemplated for dealing with the sexual dysfunctions that they might experience. Anecdotally and clinically - premature ejaculation in adolescent boys and anorgasmia in adolescent girls are common. 

         Teens are expected to control their sexual conduct without being told how to manage their desires; however, willpower and the proverbial cold shower rarely are effective.  Adolescents, particularly girls, are bombarded with double-messages that tell them to be sexy without being sexual. The resources that are available to adolescents to deal with their conflicts are abysmal. Frequently, sex education courses are based in either abstinence-only curricula (see later discussion) or classes that focus on reproductive biology, with birth control and STI prevention added. Truly comprehensive sex education is rare in the United States.

         Sexual behaviors that are viewed as unusual depend on the age and sex of the teens involved.  Boys are expected to be more sexual and more dangerous sexually.  Sex offenses committed by girls (and women) are often ignored or minimized; erroneously, girls are not even considered as possible perpetrators (7).  Paradoxically, when girls are sexually active in ways some people consider normative for boys (eg, with multiple partners), both peers and authority figures may denigrate such girls.

 

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 even 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 suggesting or condoning behaviors that violate their own moral codes or the prevailing morals of the community.  Concerns in this area cannot be ignored. 

         Forty years ago, psychiatrists typically discouraged homosexual youths from exploring and coming to terms with their sexual desires.  The stigma and alienation of that time were reinforced by long bouts of psychotherapy that were intended to “cure” homosexuality. When homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM), programs emerged to support homosexual teens, rather than to convert them to heterosexuality.  We believe that other sexual interests (e.g., fetishism, sexual sadism, sexual masochism) will be similarly reevaluated in the coming decades as the prevailing moral climate continues to change (9-12).                         

         We believe the best advice for the practicing psychiatrist is to recognize when one is depending primarily on moral beliefs and when science provides the guiding principles. Cynicism towards the latest fads is always warranted; conventional “wisdom” often is wrong.  Pronouncements that sound logical today ultimately may not be in the best interests of the patient. To avoid such pitfalls, psychiatrists are advised to seek expert sources or supervision, and examine their own visceral clutch for the possibility of countertransference reactions.

 

Normal” versus “unusual” or “abnormal” child and adolescent sexuality

         The term “unusual” implies that the sexual activity in question falls outside 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. 

         Assessment of unusual sexual activity invokes similar implicit assumptions about what constitutes normal sexual development.  A practitioner’s sense of what constitutes normal or unusual sexuality is influenced by clinical theory, empirical research, personal experiences, and socialization, cultural and religious backgrounds.  The evaluation process remains highly subjective, with consensus in only extreme cases. 

Can a minor be diagnosed with a Paraphilia?

         The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition – Text Revised (DSM-IV-TR) 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 - 18). Unquestionably, there are people who suffer or bring distress to others because of their unusual sexual proclivities.  Some describe their lack of control over sexual feelings, thoughts, or behaviors. The question is not whether such individuals exist but whether the construct of the paraphilias as described in the DSM is the best way of conceptualizing their problems.  Some of the major objections to the Paraphilia category are:

                         It is difficult to diagnose sexual psychopathology when scientific definitions of healthy and

                                        pathological sexual behavior continue to elude us. 

                         The objectivity that is required by the DSM can be compromised when diagnoses are based on

                                        atypical sexual behavior, given that such behaviors tend to evoke volatile social reactions. 

                         It is hard for clinicians to disentangle themselves from the sociocultural context in which the

                                        diagnostic process occurs. 

                         The history of the DSM indicates that sexual disorders sometimes been included or excluded

                                        (eg, homosexuality, nymphomania, hyposexual desire disorder) based on changes in

                                        social values more than because of the introduction of new evidence. 

                         There is no empirical data to prove that these behaviors, per se, create distress or dysfunction in

                                        adults. 

                         The distress or dysfunction that is associated with unusual sexual behavior may be caused by

                                        stigma or discrimination and may be alleviated by social support rather than treatment of

                                        any mental disorder. 

                         The term “Paraphilia” is often used to describe obsessional, compulsive, or impulsive sexual

                                        behaviors, though these terms are not part of DSM diagnostic criteria for the paraphilias.

         The criticisms of the paraphilias as a diagnostic entity are even more serious with respect to minors. While it is true that many individuals diagnosed with paraphilias recognize that their interests began in childhood, it is not clear how many who had unusual interests in childhood abandoned or changed those interests by adulthood.  Significant caution is warranted in applying the diagnosis of a chronic disorder with considerable negative and long-term implications to children and adolescents.  The recognition of unusual sexual behavior in childhood, without labeling it as pathological, may allow time to focus the expression of that behavior in a prosocial manner. 

 

Defining unusual sexual interests

         We do not want to repeat the historical 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 will be discussed in terms of the following considerations:

 

Frequency of sexual behaviors

         The definition of hypersexuality in adults or even whether this phenomenon actually exists is still being debated in the scientific literature (19 - 21). Psychiatry has failed to create meaningful definitions of promiscuity, nymphomania (19, 22), hypersexuality (20, 21), or similar concepts, despite decades of attempts. The latest attempts to redefine “non-paraphilic hypersexuality” (23, 24) and especially “sexual addiction” (25, 26), are more popular with the lay press than they are founded on empirical scientific data.  For minors, the problem of classification or “diagnosis” is significantly more difficult as normative frequency data for different age groups do not exist. 

         Masturbation is probably the most common sexual behavior among minors (27 - 29). Adolescents are often conflicted about masturbation; they learn that it is morally wrong in most religions but having difficulty refraining from such a pleasurable behavior.  Nevertheless, masturbation may look and feel like a compulsive behavior to the adolescent who is “ravaged” by desire.  Despite this, most adolescents outgrow the apparently “compulsive” aspects of self-stimulation as soon as partnered sex is available to them.  Partnered sex usually does not have the same “compulsive” aspects to it.  Nevertheless, many healthy teenagers seem to have a stronger interest in sexual activity than does the average adult.

           Sometimes unusual and even “unhealthy” sexual behavior may be better understood from the adolescent’s perspective.  Manzar (30) discussed the case of a Muslim male with frequent urinary tract infections resulting from masturbation with prevention of ejaculation by back-milking movements of the penile shaft.  This unusual and unhealthy masturbation method – that is intended to prevent seminal expulsion - was adopted to conform to religious teachings.  The solution may have been problematic but it did allow him to both pray and masturbate.  This case illustrates how a behavior can seem compulsive and unhealthy, but may be adaptive for the adolescent.  It is easy to imagine other, more dangerous sexual behaviors that would require intervention; however, how one defines “dangerous” and “unhealthy” is subjective.

         Any activity can become “compulsive.”  Teens are notorious for becoming “overly” interested in a particular activity for a time, often to the exclusion of other pursuits.  One can conceive of sexual preoccupation as one of these competing interests that can displace others during adolescence. 

 

Difficulties controlling sexual expression

         Children know some activities should take place in private (eg, defecation) and that others can occur in the presence of others. Failure to keep sexual activities private may suggest a problem; however, children and adolescents may not have access to an appropriate setting or time for sexual activity. For them, that does not extinguish desire, nor does it signify that the only option is abstinence. Under those circumstances, it is important to ascertain the intention and preference of the child.  Some unusual sexual behaviors may be controlled or eliminated just by allowing the child privacy. 

         Surreptitious and exhibitionistic acts should be evaluated differently. The fact that a young person was observed or caught engaging in sexual activities does not mean that the child or adolescent wanted to be seen, let alone found the behavior erotic. Furthermore, exhibitionism can exist with consensual or non-consensual observers, which can be a crucial distinction.  A desire to elicit a fearful reaction is quite different than a desire to be found attractive.  The adolescent who finds the possibility of being caught arousing should not be confused with the one hoping to avoid discovery.

         Sexual interests that become so overpowering that they interfere with other functions (eg, school or friendships), are of concern.  The “interference with functioning” is at the core of the DSM definition of a mental disorder.  Conversely, the absence of an acceptable outlet for sexual activity also may interfere with a child’s functioning. Sexual activity that the child cannot or refuses to limit to socially acceptable times and locations (eg, self-stimulation) also is considered unusual or problematic.  In other cases, the problem is not primarily sexual; the expression of the problem may be sexual (e.g., engaging in sex with numerous partners may be related to depression).  In our experience, focusing unduly on the sexual component is unlikely to bring about a satisfactory resolution. If distress or dysfunction first appear following discovery of the sexual activity, the cause of the distress may not be the sexual interest but, rather, being discovered.  A simplistic notion — for example, if the teen were to abandon the unusual behavior, the distress would be eliminated— rarely is true. It is also unwise to try to suppress sexual interests entirely.  Disconnecting adolescents from their own sexual feelings can create future sexual difficulties. The individual may not be able to reactivate sexual desire when it is later deemed socially appropriate; this is deemed "hyposexuality" in adults.   Adolescence is a time for exploration of identity, interests, and desires, including sexual ones.  Sexual dysfunction may be less frequent among adults who are raised with sex positive messages.

 

Consent

         Among individuals of all ages, one criterion for healthy sexual expression is that it is mutually consensual. Although issues of consent are more ambiguous among children and adolescents, how minors feel about consent and ascertain consent with their partners are important in the assessment of unusual sexual behaviors. Patterns of behavior are of greater concern than individual incidents, even if serious.  Among adults, misunderstandings abound and often have serious consequences.  Teenagers often have the added handicap of lack of privacy or of a suitable location and they may try to negotiate these issues while also experimenting with drugs and alcohol.  Individuals who have difficulty limiting their sexual activity to consensual partners are likely to suffer from more than just sexual behavioral improprieties.  

 

Non-heterosexual interests 

         Traditionally, major developmental theories have suggested that healthy development eventuates in heterosexuality, and, primarily, acts that could result in reproduction.  Non-coital interests are often judged as unusual, immature, or even pathologic. These acts have many motives, including experimentation, peer pressure, curiosity, or even attempts at birth control.  Peers may exert extreme pressure for adolescents to engage in sexual acts that have no erotic interests for them.  It is important to discover the motivation of the minor before assuming that the individual has a sexual concern.

         Mental health professionals often want to avoid the problems of mislabeling adolescents as homosexual in order to prevent the stigma common in our society that comes with that label in our society. It also allows us to acknowledge that some adolescents will “outgrow” this attraction.  Sexual orientation may be more fluid than is commonly believed; sexual behaviors can be extremely fluid.  We have little concern for mislabeling youth as heterosexual, although that, too, might create future difficulties. Homonegativity (dislike of or hostility towards homosexuals and homosexuality) might lead adolescents to explore heterosexual acts even if they prefer same-sex partners; reject sexual activity; or act out aggressively against those perceived to be homosexual.  Internalized homonegativity can be an important element in the elevated suicide rate among gay/lesbian/bisexual youth (9).

         There is a wide variety of sexual desires other than for conventional, heterosexual activities. Teenagers are experimenting with many new behaviors and sexual interests.  Sadomasochistic activities, group sex, cross-dressing, fetishism, the use of sex toys, and so forth may be more common than supposed.  In many adolescents, such behaviors might be transitory; however, a few behaviors become enduring parts of a given individual’s sexual pattern.

 

Sexual interests in much older or younger partners

         Concerns about sexual abuse and predatory sexual behavior are prevalent in our society. Older children, by virtue of their greater size and social skills, can coerce younger children into sexual activity, while believing that they are engaging in consensual activities; younger children often believe that they cannot disobey someone who is older. In addition, there is some concern that children who engage in sex play with other children will become fixated on partners of that age.

         It is also possible that a younger teenager will use sexual activity as a way to develop a relationship with an older teen or be seen as part of the “in-crowd.”  Sexual activity can be seen as both a rite of passage – an entry point into adulthood – and as an initiation rite for admittance to a desired group; this can be motivated by their own sexual desires and attempts to gain status with their peers. 

 

Sexual interests that incorporate atypical sexual stimuli

         Discovering a 15- year-old male masturbating to pictures of adult females is not surprising; discovering the same boy masturbating to pictures of male or female feet would more likely lead to a referral to a physician or mental health care provider. 

         There clearly is cause for concern when sexual fantasies incorporate behaviors that lead to or risk physical injury.  Masturbation with sandpaper is of greater concern than masturbation with a silk scarf. Teenagers are much more likely to be injured from sports participation or motor vehicle accidents than by unusual sexual activities. Sometimes, the object incorporated in the sexual play or how it is used creates alarm. The insertion of a perfume bottle in an orifice usually has more to do with the shape of the bottle than a sexual interest in a particular scent.

 

Number of partners

         Our society is based upon the ideal of monogamy, despite high rates of non-marital sex and divorce.  Adults in our society who indicate they are polyamorous (ie, able to love more than one sexual partner at a time) are treated with derision or regarded askance, as if they are too immature for a committed, intimate relationship.   In adolescence, the opposite is often the ideal.  Parents become concerned when the couple “goes out” together for too long, worrying that the couple may experiment with sexual activity or move on to marriage too quickly.  Adolescent girls who date a variety of different boys, still may be seen as “sluts” or as too interested in sex, even if they refrain from sexual activity. Adolescent girls are often in precarious, no-win positions. Boys who date “too much” are seen as lucky, as unable to make relationship commitments, or as just using girls for “what they want.”  There is concern that boys who do not date are social misfits, homosexual, or have other problems. Girls who do not date are perceived as either “ugly,” immature, lesbians or having some other difficulty.

 

Sexual abuse 

         Some children are forced to engage in sexual acts by others who are older or much stronger.  Typically, children have little understanding of the meaning of these acts, how they are being victimized, and the implications of their “participation.”  Even when minors believe they are participating with an adult or much older child willingly, there cannot be informed consent.  Depending on the perpetrator’s tactics, some children find the genital contact or the seemingly affectionate attention “enjoyable” at the time; some are traumatized by it, and some may be ambivalent about the experiences.  Signs of sexual abuse include fearful reactions when sexual topics are raised, vaginal discharge, and the occurrence of odd and age-inappropriate toileting behavior (31). After the sexual abuse is made public, the child may be seen as suspect, shunned by peers, or judged by others.  One fear is that they have been “sexualized” or “damaged” and will continue to act out the trauma.  Psychotherapy should be offered for the child and family, as should guidance for teachers and other caregivers. Children should receive information on the difference between sexual coercion and appropriate sexual expression and on the meaning and role of consent. Feelings of guilt, shame and of being defective must be explored and alleviated.

 

Dangerous sexual behaviors

         Dangerous sexual behaviors are various and potentially extensive in scope and might be considered unusual behaviors by fiat; they will be 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, peanuts) into the vagina; this is a more unusual behavior in older girls, presumably because of the greater cognitive recognition of risks or other social implications.  Early school-age boys may tie something around their penis; pubescent boys may place objects into the urethra (and occasionally lose them).  In these cases, a urologist and a psychiatrist or psychologist may provide important liaison functions for both the pathophysiologic ramifications of such behaviors and for a determination of psychosexual developmental atypia or unacceptable levels of further risk.  More longitudinal assessment and observations may be important; interventions most commonly involve parent-patient education.

         Sexual behaviors dangerous to others — sexual predation by one child towards others — require a more involved assessment by an experienced psychiatrist or psychologist.  Liaison with a pediatrician or a pediatric urologist is again important.  Other important factors and perceptive recognitions include not only the relative ages of the predator to the recipient, the level of sexual intimidation, and the degree of sexual maturation of the offending child.  It is important to recognize sexual impulse control problems (especially in the adolescent) while providing education and structure for parent-monitoring for both older and the younger child.   Clinical experience in a Psychosexual Development Clinic has found that similar sexual experiences among children may have clinically significant psychosexual ramifications for some children, but not necessarily for others; girls may exhibit higher overall risks (for example, see ref. [32]).  

 

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 sexual experiences with other - particularly older- children.  Generally, parent monitoring and parent and child education or other psychoeducational techniques are useful.  Longitudinal assessment may be of benefit.

         Some unusual sexual behaviors require interventions because they are illegal or offensive.  Again, pre-adolescent and pubescent boys are over-represented here.  Brief, but recurrent, exhibitionism is not an uncommon behavior in preadolescent boys, especially in the 10-to 12-year-old age group.  Such behaviors generally occur outside the family and tend to offend other children’s parents.  Persistent and more directed exhibitionism, generally in the mid- or late adolescent, is a rare occurrence often first discovered by a child’s parents when he is arrested; it can have serious legal consequences.  The origin of such behavior is unclear; interventions may not be of great benefit the child.

         Sexual behaviors that generally are known as fetishes are often first recognized by parents or by an older sibling.  These behaviors are complex and commonly involve erotic stimulation or imagery by stealing of or wearing female undergarments or clothing; these behaviors are brought to clinical attention when a boy reaches about 11 or 12 years of age.  Signs of such unusual sexual interests at younger ages may be more likely related to obsessive-compulsive-like phenomenology; in rare circumstance, these may respond to interventions that are aimed at the underlying obsessive-compulsive phenomena.  More typically, however, such behavior responds only to educationally-oriented approaches to down-play the behaviors and protect the child from discovery while protecting members of the household from conflict or embarrassment in family dynamics.  These behaviors are complex in nature and difficult to inhibit.

 

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 more nearly acceptable (or “normative”) can be useful and important; however, bridging techniques are likely to require intermittent and sometimes frequent reinforcement.  If legal offense is likely — as in exhibitionism in the late adolescent — clinician-reporting before the child has offended is generally considered unethical, illegal, or both; generally, legal institutions have no recourse before an offense is committed.  Continued involvement of the clinician can be important after the child has offended.  In such conditions, protection is difficult for the potential offender or for those likely to be offended against.  The clinician must be persistent, firm, and judgmental of behaviors but without rejecting the child himself.  

 

 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 particularly 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 their interests secret because these minors are scrutinized more closely; therefore, it is less likely that their behavior will go unnoticed.   This may be one reason why there seems to be an association between youth who are diagnosed with psychiatric problems and so-called, but commonly undefined “sexual acting out”; more attentive (or perhaps intrusive) surveillance is more likely to uncover private behaviors.  Additionally, any provider who assures minors that they can confide freely about any thoughts or behaviors needs to be capable of “handling” that adolescent’s disclosures.

 

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 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 indicates moral weakness or psychologic problems). Under abstinence-only sex education guidelines, the only statement high school teachers in Anchorage, Alaska can make to students about masturbation is: "Masturbation, though no longer considered harmful, is a practice which some groups you may belong to do not condone" (33). A minor improvement from abstinence-only sex education is abstinence-based sex education, which consists primarily of abstinence-only sex education plus some birth control and STI prevention information. Neither of these approaches adequately prepares teens to understand the range of sexual options available or to grapple with the sexual issues facing our society or that they will face (e.g., gay marriage, the meaning of the Clinton/Lewinsky affair). Unwanted pregnancies and STI rates are used to evaluate the success of sex education programs; these are questionable measures of an academic program. Research demonstrates that abstinence-only programs have failed (34-36) in the prevention of teenage pregnancy and STIs and in preparing adolescents to navigate sexual challenges.  A special issue of SIECUS Reports (37) described the adverse impact of abstinence-only sex education on American adolescents (in their own words).

         An alternative is comprehensive sex education, which emphasizes broad-based knowledge of all aspects of sexuality, thereby enabling students to make informed decisions about sex. In addition, it incorporates discussion of sexual feelings and desires, risk-reduction strategies; and rehearsal of relationship, communication, and negotiation skills. The research indicates that such programs are significantly more effective in delaying sexual activity and in reducing STIs and unwanted pregnancies (38,39). 

         Sex education could have an invaluable role in guiding children towards respectful, responsible and mutually-fulfilling sexual relations.  When government severely restricts sex education in the United States, teens who have been kept largely sexually ignorant will be ill-prepared for possible consequences of engaging in sex.  As a corollary, whether current sex education programs affect the prevalence of unusual sexual behavior, they are likely to isolate children who have such concerns and to impede counseling or consoling for them. 

 

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 both 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 sexuality with shame. Guilt-laden or anxious reactions to childhood sexual conduct may be more problematic to the child and adolescent than the actual behaviors (42).

          In general, typical children appear to experiment with many different sexual behaviors during childhood and adolescence. An adult's focus on a particular behavior may have undesirable effects.  Prohibitions may actually focus interest on the forbidden.  Thus, adult admonitions may play a pivotal role in determining whether sexual experimentation remains exactly that or becomes more entrenched developmentally.

         Socially, behaviors that are illegal, nonconsensual, or dangerous need to be discouraged.  This may be best accomplished by giving the child or adolescent more options.  It is much easier to replace the thought of a pink elephant with a blue tiger than with a directive not to think.   A common, dangerous sexual behavior among adolescents is unprotected coitus. The solution to this problem lies in educating young people about the risks of unprotected, penetrative sex and teaching them about abstinence and safer sex. Ironically, American reluctance to confront this problem openly and directly highlights the difficulty that parents, schools and psychiatrists face in dealing with atypical sexuality in children andin suggesting appropriate, alternate forms of expression.

 

Sexual behavior for “non-sexual” 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, 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 unrelated to their own sexual interests.  This occurs when they are victimized, such as in child pornography, prostitution and other sexual abuses.  Sex work is one of the few ways that minors can be financially independent enough to escape other abusive situations.  

         Illicit drug use — procuring or imbibing — can also be a motive for sexual activity.  For example, the sale of sex can fund drug procurement. Furthermore, some drugs decrease inhibitions and internal resistance to the activity itself.  Sorting out the more important of these motivated behaviors can be elusive.  Additionally, the lowering of inhibitions may or may not reveal an individual’s actual sexual interests.  At least among adults, there are individuals who have no interest in their atypical sexual acts when sober and drug-free.

         A variety of developmental or psychiatric problems also can lead to unusual sex practices.  A depressed teenager may escalate the level of sexual activity to find something that relieves psychic pain.  Other teens who have poor judgement may believe erroneously that they can perform unusual and risky behaviors safely.  Working with these teens to deal with the underlying problems may mitigate unusual sexual behaviors.   

        

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 recognition that one has an unusual sexual interest, some individuals attempt to extinguish their arousal patterns, whereas others embrace them.  We do not know how people develop sexually or what leads them to accept or reject their own patterns.        

 

The role and impact of sexual abuse

          A prevalent and rather typical assumption in the literature is that unusual sexual behaviors are caused by child sexual abuse (43-47). The data to support this statement is lacking and there are many other possible explanations (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 later abuse others (49-52).  Only a small percentage of individuals who have been victims of child sexual abuse will victimize other children (53,54).  Causation is unclear regardless of findings; valid study methods are unavailable. The literature also suggests that child sexual abuse inevitably cause sexual dysfunctions or other psychiatric sequelae (55-58). The assertions are that the abuse itself, as well as the resulting intrapsychic and interpersonal difficulties, can lead to various sexual problems and concerns that become apparent in adolescence and adulthood (55-60).  These problems then include aversion to various body parts and sexual acts; feelings of being “dirty”; poor body image; difficulty initiating or declining sex; withdrawal; feeling emotionally empty; and sexual dysfunction (55-61).  Epidemiological follow-up with valid study methods is lacking.  Clinical experience seems to refute that such outcomes are inevitable.  

         Although a history of sexual abuse may be correlated with unusual sexual behavior it does not necessarily follow that it is the consequence or that unusual sexual behavior is caused by sexual abuse. Clinicians should assess for a history of sexual abuse when a child is referred for unusual sexual behaviors (or other psychiatric problems) just as they should assess sexual activities.  If abuse has occurred, it is prudent to deal with psychological consequences and their impact on sexual expression rather than targeting any unusual sexual conduct in isolation.

 

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 non-coital 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 difficult to imagine any researcher would receive funding or approval to conduct a large-scale, descriptive study of childhood sexual desire and expression.

         Most adolescents engage in sexual behaviors - whether with partners or alone - at least occasionally.  Sexual experimentation in adolescence, whether alone or with partners, can provide a platform for rehearsal of future adult sexuality.  Most adolescents do not have access to sexual information that would allow them to decide which sexual behaviors that they would be most interested in exploring.  Rather they experiment with what is available, sometimes with amusing results. In 2002, the Harry Potter vibrating broomstick was sold as a toy primarily for prepubescent children; however, it quickly became a favorite masturbation device among teenage girls. Parents complained and often removed the batteries, but there is no indication that they used the opportunity to discuss masturbation with their children (64). Children and adolescents experiment with sensations and noxious stimuli that adults often find unpleasant (eg, roller-coasters).  It is not surprising that their sexual explorations can be unusual. 

 

Unusual sexual interests and concurrent psychiatric concerns

          Underlying psychosexual development may both 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 differentiating at least some individuals who have unusual sexual interests and are likely to commit sexual offenses (65). There are individuals who have unusual sexual interests who never acted upon them or never act upon them inappropriately.  Differentiation between sex offenders and non-offenders seems to be linked less likely to sexual content or sexual ideation than to the impulse dyscontrol or social deviance (66). We do not understand what leads some persons to be able to control their impulses while others cannot. 

         Adult sex offenders are often diagnosed with Antisocial Personality Disorder.  Similarly, Conduct Disorder seems to be the most prevalent diagnosis among adolescent sexual offenders (64).  According to DSM-IV-TR criteria, to be diagnosed with Antisocial Personality Disorder, requires being diagnosed previously with conduct disorder.  Nevertheless, most persons who are diagnosed with conduct disorder are not later diagnosed with Antisocial Personality Disorder (13).  This implies that adolescent sex offenders will not become adult sex offenders necessarily.  

         There is some evidence to suggest that social conditions are linked with psychiatric symptoms in children; improvement in social conditions can ameliorate psychiatric presentation.  In one study, exiting from poverty significantly decreased the incidence of symptoms associated with Conduct and Oppositional Defiant Disorders to the level of those who had never been poor (67).   

           A negative parental or social focus on the unusual sexual behavior itself may also be an issue for children.  Typical psychosexual developmental patterns—or pitfalls—in these children are unclear.  As has been demonstrated with gay and lesbian youth, teens who can find a community of others who share their interests may fare better psychosocially than those who are isolated (9,68,69).   Adolescents who find positive information about their sexual interests may well fare better than those who are believed to be psychiatrically ill.   

 

Summary

Our understanding of unusual sexual interests in children and adolescents is in its infancy.   This manuscript 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 themselves 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.  The literature on unusual sexual interests tends to focus on adolescent sex offenders - a selection bias of social safety.  Yet this approach has not been beneficial for an understanding of the nature of unusual sexual interests themselves or of which behaviors require clinical—as opposed to legal—interventions.  We do not know why or how some children become interested in unusual sexual expression.  We do not know which individuals will “outgrow” these interests or in whom they will endure.  We do not know when such behaviors need to be treated or the effects or the efficacy of such treatment interventions.  Rational interventions are difficult to formulate before the recognition of relevant phenomenology.   Additionally, interventions for unusual sexual behaviors in children and adolescents have potentially profound and lasting social and legal effects; however, parental and social approaches to children who have unusual sexual behaviors are neither rational nor consistent.  Sex education programs in the United States suffer a similar design that is not rational.  

We are in need of comprehensive studies of child psychosexual development and outcome.  We would also benefit by educating our parents, educators, legislators, and health-care providers about child sexuality—and what we do not know about it.  Therefore, current clinical approaches to unusual sexual behavior in children and adolescents are misguided.  Future research must consider our paucity of outcome data and cultural factors (eg, gender, socioeconomic factors, and sexuality- biases) in investigating unusual sexual behavior.  Mental health professionals need additional information to make more effective assessments and clinical interventions.

 

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