Sexual Behavior in Infancy and Early Childhood

1. Sexual Behavior inInfancy and Early Childhood John S. Rozel, MD

2. Goals • The participant will understand what is and is not known about early sexual development (Ages 0-12) • The participant will critically evaluate normal and abnormal sexual behaviors • The participant will gain understanding of when and how to intervene and when and how to obtain further evaluation

3. Outline • Introduction • Normal development • What are and are not abnormal behaviors • Basic interventions • When and where to refer • Discussion

4. Introduction: Development • Childhood, sexuality, development, sexual abuse • Ancient phenomena but new concepts • Development is a process • Sequence set • Rate of progression variable • “Range of behavior” -- difficult to distinguish normal from abnormal at times

5. Introduction:Why study & intervene? • Part of development • Possible indicator of abuse • Behaviors are highly problematic to manage • Behaviors put the child and others at risk • Prevention of further victimization

6. Introduction:Context • Development strongly influenced by culture • Temporal • Social • Privacy • “Innocence” • Latency

7. Culture & Society

8. Culture & Society

9. Introduction:Context • Development strongly influenced by culture • Temporal • Social • Privacy • Children not protected until Victorian era • “Innocence” • Latency Jackson, 1993

10. Freud & Latency • Early development: oral, anal, genital • Latency: ~5-12 yrs of age • Sexuality dormant? • No, sexuality hidden from adults • Cross cultural studies and historical documents • “adult” sexual behavior even in 6-8 year olds

11. Challenges in studying child sexual development • New field • No money • Highly sensitive topic - parents unlikely to consent • Children learn to hide behaviors • Since children are “innocent” and “asexual,” most existing work is pathology-oriented

12. Sexual development • Children are born with the capacity for sexual arousal and function • Sexual behavior is learned • Sexual behaviors are likely to be repeated because they are very reinforcing • Intimacy • Arousal • Orgasm • Tension reduction Ryan, 2000a

13. What is normal or abnormal? • Highly associated with culture and individual developmental trajectory • Primarily observational data • Friedrich (Mayo Clinic) & the Child Sexual Behavior Inventory • Extensively validated on thousands of children: • General population, known-abused, psychiatric • US & Europe • Parents best reporters

14. CSBI • 35-item behavior checklist • Ages 2-12 • Total score differentiates normative and sexually abused children • Three revisions • Yes/No or Frequency • never • less than once a month • one to three times a month • at least once a week Friedrich 1992 and 2001

15. Puts mouth on sex parts Asks to engage in sexual acts Masturbates with objects Inserts objects into vagina or anus Imitates intercourse Sexual sounds French kisses Undresses other people Asks to watch explicit TV Imitates sexual behavior with dolls Wants to be opposite sex Talks about sexual act Touches other’s sexual parts Rubs body against people Hugs strange adults Shows sex parts to other children Uses sexual words CSBI items Friedrich, 1992

16. Uses sexual words Overly aggressive or passive Talks flirtatiously Masturbates with hand Looks at nude pictures Shows sex parts to adults Interested in opposite sex Tries to look at people undressing Touches breasts Touches sex parts at home CSBI items Friedrich, 1992

17. CSBI itemsnonsignificant • Dresses like opposite sex • Pretends to be opposite sex • Kisses nonfamily children • Kisses nonfamily adults • Sits with crotch exposed • Undresses in front of others • Scratches crotch • Uses opposite sex toys Friedrich, 1992

18. Normative boys Mean 10.60 SD 7.64 Normative girls Mean 11.72 SD 8.32 Abused boys Mean 20.51 SD 18.18 Abused girls Mean 18.07 SD 11.97 Total scores: Age 2-6 Friedrich, 1992

19. Normative boys Mean 5.56 SD 5.95 Normative girls Mean 5.35 SD 6.14 Abused boys Mean 16.69 SD 15.37 Abused girls Mean 11.19 SD 12.92 Total scores: Age 7-12 Friedrich, 1992

20. CSBI • Psychiatric patients “somewhere in between” • “Sexual behavior not unique to sexually abused children” Friedrich, 2001

21. Spurwink Study • Forensic referrals subjected to CSBI • Strong evidence of abuse: Diagnostic medical findings, credible and reliable statements made by child • No significant relationship between a diagnosis of sexual abuse and presence or absence of sexual behavior problems Drach, 2000

22. Categorically abusive behavior • CSBI not designed to delineate which children need intervention • Ryan, 2000a proposes “categorically abusive behavior” which requires clinical intervention • Sexual behavior between two children with • Lack of consent • Lack of equality • Coercion

23. Lack of Consent • Not knowing what is proposed • Dissimilar knowledge of standards of behavior • Dissimilar knowledge of potential consequences • No ability to freely choose without repercussions Ryan, 2000a

24. Lack of Equality • Obvious differences in age, size, intellect, responsibility • Being in charge, baby-sitting • Subtle differences in strength, popularity, self image • Role differences: leader, boss, fantasy roles in play Ryan, 2000a

25. Coercion • Manipulation, trickery, peer pressure, bribes • Threats of lost relationships, privileges, or esteem • Threats of force or harm, intimidation • Physical restraint, force, weapons, violence Ryan, 2000a

26. Prenatal behaviors • Oral: Thumb sucking • Genital: Erection

27. Masturbation • Frequently done by caregivers to children historically and, still, in some cultures • Seen in infants as young as 2-4 months

28. Distinguishing behaviors • Normal • Of concern • Problematic

29. Preschool - Normal • Touches genitals for exploration and pleasure, to relieve tension • Explores gender differences • Touches genitals and breasts of familiar adults and children • Looks at nude persons • Asks about genitals, breasts, intercourse, babies • Erections Johnson, 1993 and Galenson, 1993

30. Preschool - Normal • Likes to be nude, may show others genitals • Uses dirty words • Investigates anal area in themselves, others, toys, etc. • Interested in watching people doing bathroom functions • Interested in having a baby • Interested in feces Johnson, 1993

31. Preschool - Normal • Plays doctor • Puts something in genitals or rectum of self or other child owing to curiosity or exploration • Plays house, acts out roles of mommy and daddy Johnson, 1993

32. Preschool - Of concern • Continues to touch or rub genitals in public place after being told no many times • Continuous questions about genital differences after they have been answered • Touches genitals, breasts of adults not in family • Asks to be touched himself/herself • Stares at nude persons even after seeing many people nude Johnson, 1993

33. Preschool - Of concern • Keeps asking about genitals, intercourse, breasts, babies even after parent has answered questions at age appropriate level • Continuous erections • Wants to be nude in public even after parents say no • Interest in watching bathroom functions that does not wane in days to weeks Johnson, 1993

34. Preschool - Of concern • Boys’ interest in having a baby does not wane after several days or weeks of play about babies • Uses dirty words at home even after parent says no • Smears feces on walls or floor more than one time • Frequently plays doctor even after being told no Johnson, 1993

35. Preschool - Of concern • Puts something in genitals or rectum of self or other child after being told no • Humping other children with clothes on Johnson, 1993

36. Preschool - Problematic • Touches or rubs self in a masturbatory fashion, in public or private, to the exclusion of normal childhood activities • Plays male or female roles in an angry, sad, or aggressive manner • Hates own or other sex • Sneakily touches adults • Makes others allow touching • Demands touching of self Johnson, 1993

37. Preschool - Problematic • Asks people to take off clothes • Attempts to disrobe others forcibly • Aasks strangers about breasts, genitals, intercourse, babies after parent has answered • “Precocious” sexual knowledge • Painful erections (Could be medical) • Refuses to put on clothes Johnson, 1993

38. Preschool - Problematic • Secret exposes self in public after many scoldings • Refuses to leave people alone in bathroom • Displays fear or anger about babies, birthing, or intercourse • Uses dirty words in public or at home after numerous scoldings • Repeatedly plays or smears feces after scolding Johnson, 1993

39. Preschool - Problematic • Forces child to play doctor or take off clothing • Any coercion or force in putting something in rectum or genitals of other child • Simulated or real sex without clothes on Johnson, 1993

40. School aged children • Have robust sexual imagination • Many questions • Emerging modesty • “School yard mythology” • Gender solidification • Gender separation Rosenfeld, 1993

41. School aged - Normal • Interest in urination and defecation • Touches or rubs own genitals when going to sleep, when tense, excited, or afraid • Plays house, may simulate all roles of mommy and daddy • Thinks other-sex children are gross, have cooties, and chases them • Talks about sex with friends, Johnson, 1993

42. School aged - Normal • Talks about having a girlfriend or boyfriend • Wants privacy in bathroom or when changing clothes • Likes to hear and tell dirty jokes • Looks at nude pictures • Plays games with same-aged children related to sex and sexuality • Draws genitals on human figures Johnson, 1993

43. School aged - Normal • Explores differences between males and females • Takes advantage of an opportunity to look at nude child or adult • Pretends to be opposite sex • Wants to compare genitals with same-aged friends • Kissing familiar adults and children Johnson, 1993

44. School aged - Normal • Wants to touch genitals, breasts, buttocks, of other same-aged child or have child ouch him or her • Allowing kissing by familiar adults or children • Looks at genitals, buttocks, breasts of adults • Erections • Outs something in own genitals or rectum • Interest in breeding behaviors of animals Johnson, 1993

45. School aged - Of concern • Continues to touch or rub genitals in public after being told no • Masturbates on furniture or with objects • Humping other children with clothes on • Imitates sexual behavior with a doll or stuffed toy • Uses dirty language when other children really complain Johnson, 1993

46. School aged - Of concern • Sex talk gets child in trouble • Romanticizes all relationships • Becomes very upset when seen changing clothes • Keeps getting caught telling dirty jokes • Makes sexual sounds • Continuous fascination with nude pictures • Wants to play sex-related games with much younger or older children Johnson, 1993

47. School aged - Of concern • Draws genitalia on only certain figures • Genitals disproportionate to size of body in drawings • Remains confused about gender differences even after questions answered • Stares at or sneaks looks at nude persons after having seen many nude people -- beyond exploration • Wants to be opposite sex Johnson, 1993

48. School aged - Of concern • Wants to compare genitals with much older or younger children or adults • Continuously wants to touch genitals, breasts or buttocks of other child or children • Tries to engage in oral, anal or vaginal sex • French kissing • Talks in sexualized manner with others Johnson, 1993

49. School aged - Of concern • Fearful of hugs and kisses by adults • Fearful of public displays of affection • Touches or stares at breasts, buttocks, genitals of adults • Asks adults to touch them on genitals • Continuous erections • Touches genitals of animals Johnson, 1993

50. School aged - Problematic • Touches or rubs self in public or private to the exclusion of normal childhood activities • Humping other children naked • Intercourse with another child • Forcing sex on another child • Uses bad language against other child’s family • Targets other-sex children for violence Johnson, 1993