Patient Presentation
A 3-year-old male came to clinic for his health supervision visit. His mother had no real concerns but stated that since he was toilet training she had noticed that he also was doing a fair amount of masturbation. “I haven’t said anything to him but he’s doing it at the grocery store or at the playground with other people around. I’m not sure what to do or say,” she stated. During the interview the mother also said that he did not seem to have other worrisome sexual behaviors nor was she worried that he might have been sexually abused.
The pertinent physical exam showed a healthy male with growth parameters at the 90-95%, with normal vital signs. His examination was normal including noting that he was circumcised with bilateral testicles in the scrotum. The diagnosis of a healthy male was made. The pediatrician, responded that masturbation in a child of this age appeared to be normal as the behavior did not cause him distress, he did not have other sexual behaviors and was otherwise well. He recommended that the mother start to help him set appropriate personal boundaries by stating something like, “I know that rubbing your penis feels good, but that is only something you can do in private by yourself. You can do that in your bedroom or in the bathroom, but you shouldn’t do it at the playground with other people around.” The pediatrician also recommended that the mother teach him proper names for male and female genitals. As he probably would be asking more specific questions about body parts and bodily functions, the pediatrician recommended to answer the questions in a straightforward manner and use that as an opportunity to teach him about his growing sexuality.
Discussion
People of all ages, including both ends of the age spectrum, are sexual beings. It is a part of being human. Children will learn about their own and others sexuality both verbally and physically. Normative studies of young children’s sexual behavior were done in the 1990’s and showed a wide array of normative verbal and non-verbal behaviors at different ages, from potentially innocuous (i.e. stands too close to people) to potentially invasive (i.e. touches private parts of other children). Children who exhibit the most sexual behaviors are those < 4 years with basically a steady decline starting around 5 years of age. This is true for both sexes. This may be due to children learning that these are private behaviors and thus parents are less likely to see and report the behaviors.
Some parents worry that discussing sexuality will encourage sexual behaviors. Data does not support this viewpoint. Pediatricians and other health care providers can help educate families that teaching their children about sexuality is important. Providing straightforward answers gives the children information so they can make good choices about their own bodies and health which affects them directly and their families and communities indirectly. Parents are often concerned that the behaviors they notice are not normative and that they will not be able to answer their children's questions.
Some basic information for parents to consider when discussing sexuality with their children includes:
- Offer simple, accurate information for the question being asked. Depending on the child’s age and knowledge, offer simple basic information about bodily functions including urination, defecation, puberty, sexual reproduction, pregnancy and childbirth.
- Have the child re-ask the question or explain their question so parents can make sure they are answering the correct question.
Children will often ask a question that adults mis-interpret. For example, a 3 year old child asks, “Where do babies come from?” When asked to repeat it, the child states, “Do babies come from mommies or grandmas too?”
After the explanation if the child seems confused or not satisfied with the answer, ask “What doesn’t make sense?” or “What else can I answer for you?” This lets the child clarify the answer or ask other questions. - Make and reinforce personal boundary rules such as private parts should be covered, one does not touch other people’s private parts, touching private parts should occur only in private
- Provide accurate names for male and female body parts from the onset
- Masturbation is a normal behavior at any age, but it should be done in private
- In older children, provide basic information about sexual activity risks including pregnancy and contraception, sexually transmitted infections and prevention methods
- Provide sexual safety information such as your body belongs to you. The child can say NO at any time if someone’s touches makes them feel bad. Teach ways to avoid risky situations such as stranger safety and dating rules.
- Even if parents are uncomfortable that they may say something wrong, they are communicating with the child and trying to answer their questions. Its okay to say, “I don’t know” and then find an answer. A child is more likely to continue to talk about sexuality and other topics with the parent if all communication at home is open.
Parents and healthcare providers should be concerned if any sexual behaviors include anything that:
- Is clearly beyond the child’s developmental age
- Involves children of widely different ages
- Causes strong emotions in the child
- Involves aggression, threats or force
Learning Point
Common sexual behaviors in children < 12 years old includes:
- < 4 year old
- Asks questions about own/others body and bodily functions
- Talks with children of same age about bodily functions
- Removes clothes and wants to be naked
- Show other people his/her own private parts
- Tries to see other people who are undressing or naked
- Explores or rubs private parts (with hand or objects) in private or public
- 4-6 year olds
- Talks about private parts and uses slang (i.e. “naughty”) words. May not understand the word he/she is using
- Tries to see other people who are undressing or naked
- Masturbates in private or occasionally in public
- Explores private parts with children of own age (i.e. plays doctor)
- Mimics dating behaviors such as hand holding or kissing
- 7-12 year olds
- Beginnings of sexual attraction or interest in peers
- Desire for privacy increases such as locking bathroom doors, not wishing to un/dress in front of others.
- Tries to see other people who are undressing or naked
- Views/listens to media with increased sexual content
- Views media of naked or partly naked people
- Masturbates usually in private
- Plays games that involve sexual behavior with same age peers (i.e. “boyfriend/girlfriend” “truth or dare”)
Questions for Further Discussion
1. What are normative sexual behaviors for teenagers?
2. What types of sexual behaviors may indicate that a consultation with a child maltreatment specialist is indicated?
Related Cases
- Symptom/Presentation: Health Maintenance and Disease Prevention | Behavior Problems
- Specialty: General Pediatrics | Preventive Medicine and Health Maintenance | Child Abuse and Neglect
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Sexual Health, Toddler Development and Teen Health.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Friedrich WN, Grambsch P, Broughton D, Kuiper J, Beilke RL. Normative sexual behavior in children. Pediatrics. 1991 Sep;88(3):456-64.
Friedrich WN, Fisher J, Broughton D, Houston M, Shafran CR. Normative sexual behavior in children: a contemporary sample. Pediatrics. 1998 Apr;101(4):E9.
National Child Traumatic Stress Network. Sexual Development and Behavior in Children. Available from the Internet at http://nctsn.org/nctsn_assets/pdfs/caring/sexualdevelopmentandbehavior.pdf (rev. 4/2009, cited 5/28/2013).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 