Early Childhood: Infants, Toddlers, and Preschoolers (Aged 0 to 6 years)

School-Aged Children (Aged 7 to 12 Years)

Adolescent Sexual Development (Ages 13 to 19 Years)

Cultural Factors Affecting Sexual Development and Behavior

Children’s public and private sexual behavior, modesty, intimacy, and relationships are affected by their family’s and communities’ cultural values, beliefs, norms, religion, spirituality, socioeconomic, historical, and other factors. For example, social environments with norms in which nudity is acceptable, privacy is not reinforced, and exposure to sexualized material is common have been found to be related to higher frequencies of sexual behaviors in the children than are social environments that reinforce modesty and privacy.²⁸

Parents’ attitudes toward children’s sexuality have been found to affect children’s sexual knowledge and behavior.¹⁹ Cultural beliefs may explain normative differences found in cross-cultural studies. For example, mothers of Dutch children report greater frequencies of sexual behaviors in their preschool-aged children than do mothers of American children, which may be related to a more permissive, positive attitude about sexuality and nudity in The Netherlands than in the United States.³⁰ Cultural differences in children’s sexual knowledge (such as physiological distinctions between sexes, pregnancy, and birth) have also been found. For example, preschool-aged girls in the Western hemisphere have been found to perceive that babies were always in their mother’s bellies, whereas Asian boys thought the baby was swallowed.¹⁶

Factors may interact, and differences in regard to norms between boys and girls are not uncommon. Implicit and explicit messages about sexual behavior are provided to children and youths through family, friends, neighbors, and the community, as well as a variety of media (including television, movies, music videos, music lyrics, video games, magazines, the Internet, and communications with cell phones). How children sort out the multiple and often conflicting messages about sex, sexuality, and relationships are not clearly understood. However, reduced risk-related behaviors have been found with attentive parenting with close supervision and good communication. Entertainment television can also have a positive effect on youth knowledge, particularly when paired with good communication with parents.⁶³ Ways in which culture may affect educational and intervention approaches are discussed later in the section on intervention.

Homosexuality

Homosexuality does not begin during adolescence. However, adolescence is the most likely time during childhood that concerns about sexuality, sexual orientation, and sexual behavior are presented to the developmental-behavioral pediatrician.

Many youths experiment with and explore a range of sexual behaviors, including sexual behavior with people of the same and opposite sex.^2,49 Sexual exploration and behavior are not synonymous with sexual orientation.⁶⁴ With whom youths have sexual behavior may be more strongly related to who is regularly in their social environment than with sexual orientation. Adolescents with homosexual experiences may identify themselves as having a heterosexual orientation. Furthermore, adolescents with no sexual experience or only heterosexual experiences may identify themselves as homosexual or bisexual.⁴⁹

National data suggest that 2.3% of men and 1.3% of women in the United States are self-identified as homosexual.⁶⁰ In the same survey, 1.8% of men and 2.8% of women described themselves as bisexual.⁶⁰ Accurate prevalence rates are difficult to calculate because of the continuing stigmatization of homosexuality.⁶⁴ In a survey of junior and high school students from Minnesota, approximately 88% self-identified as heterosexual, 1.6% of boys and 0.9% of girls identified themselves as either primarily homosexual or bisexual, and more than 10% were “not sure” of their sexual orientation.⁶⁵ More information on homosexuality and development is available in Chapter 25C.

Children and Adolescents with Developmental Delays and Disabilities

Sexual development can be more variable when children and youth have developmental delays or disabilities or chronic medical conditions. Developmental disabilities and medical conditions may be associated with precocious or early-onset puberty (e.g., Down syndrome, traumatic brain injuries, and tumors, including hamartoma), delayed puberty (e.g., Prader-Willi syndrome), or disrupted sexual development (e.g., spinal cord injuries).^3,66,67 Historically, professionals and family members have inadequately understood, accepted, and responded to sexual development in individuals with disabilities.^3,67 However, as in all children, sexual arousal and sexual behaviors begins at or around birth, pubertal development with the associated sexual feelings typically occurs, and many adolescents with developmental disabilities date and are sexually active.⁶⁸ Unfortunately, many youths with developmental disabilities have not been provided developmentally appropriate sexual education.^67,69 Providing sex education for children with developmental delays is discussed in the section on recommendations concerning clinical care later in this chapter.

Effect of Sexual Abuse on Childhood Sexual Knowledge and Behavior

Sexual abuse affects children’s sexual knowledge, as well as their sexual behavior. Furthermore, sexually abused children have been found to have greater frequencies of a wide range of sexual behaviors in comparison with normative samples and with children who were clinically referred with no known history of sexual abuse.^28,70,71 Sexually abused preschool-aged children are at greater risk for inappropriate sexual behaviors (35%) than are sexually abused school-aged children (6%).⁷⁰

Although most sexually abused children do not demonstrate SBPs, the presence of SBPs raises concern about child sexual abuse and exposure to sexual material. Professionals need to be well aware of the child abuse reporting statutes in their jurisdiction, because reports of suspected sexual abuse may be necessary. Specific sexual behaviors (such as playing with dolls imitating explicit sexual acts and inserting objects in their own vaginas or rectums) are more likely to occur in children who have been sexually abused than in those who do not have a suspected history.^27,30,72 The presence of sexual behavior maybe enough to suspect sexual abuse and report to authorities for investigation; however, sexual behavior itself cannot be a sole determining factor for diagnosing sexual abuse.⁸ Confirming sexual abuse in young children is quite complex, because often there is no physical evidence and no witnesses, and aspects of the abuse (e.g., threats by the perpetrator) hamper clear reporting by the child.⁷³ Additional information on identification and reporting of and response to suspected sexual abuse is provided in The APSAC Handbook on Child Maltreatment (2ed) by Myers JEB, Berliner L, Briere J et al, 2002.

Problematic Sexual Behavior during Childhood (Ages 3 to 12 Years)

Sexual behavior in childhood occurs on a continuum from typical to concerning to problematic.⁷⁴ SBPs do not represent a medical/psychological syndrome or a specific diagnosable disorder; rather, they represent a set of behaviors that are well outside acceptable societal limits.⁸ SBPs in this context are defined as child-initiated behaviors that involve sexual body parts (i.e., genitals, anus, buttocks, or breasts) and are developmentally inappropriate or potentially harmful to themselves or others.¹ SBPs may range from problematic self-stimulation (causing physical harm or damage) to nonintrusive behaviors (such as preoccupation with nudity, looking at others) to sexual interactions with other children that include behaviors more explicit than sexual play (such as intercourse) to coercive or aggressive sexual behaviors (of most concern, particularly when paired with large age differences between children).

Although the term sexual is used, the intentions and motivations for these behaviors may not be related to sexual gratification or sexual stimulation. Rather, the behaviors may be related to curiosity, anxiety, reenacting trauma, imitation, attention-seeking, self-calming, or other reasons.¹

Children as young as 3 and 4 years of age with SBPs have been described in the literature.^75–78 Girls may be somewhat more likely than boys to be referred for services for SBPs during preschool years⁷⁸ and boys during the school years.^79,80 However, no population-based statistics on the incidence or prevalence of SBPs in children are available. By definition, most of the sexual behaviors involved are fairly rare.²⁸ Since the 1980s, there has been an increase in the number of children with SBPs who have been referred for child protective services, juvenile services, and treatment in both outpatient and inpatient settings.⁸¹ The increase in referrals may represent an actual increase incidence of such behaviors, changing definitions of problematic sexual behavior, improved awareness and reporting of what has always existed, or some combination of these factors.⁸

The prevalence of sexual behavior for specific races, ethnic groups, religious groups, and socioeconomic groups is unknown. In groups in which there are extremely high rates of sexual abuse at a young age, the children are at higher risk for developing problematic sexual behaviors.

Problematic Sexual Behavior during Adolescence

Adolescent sexual offenders are adolescents between the ages of 13 and 17 years who commit sexual behavior that is illegal as defined by the sex crime statutes of the jurisdiction in which the offense occurred.¹²¹ In general, the legal system (i.e., family or juvenile court, probation officer, judge, district attorney) is involved when an adolescent commits a sexual crime, because of the adolescent’s assumed culpability in committing the crime. The response of the legal system to an adolescent’s sexual crime varies greatly by state and may include court-ordered treatment, probation, imprisonment in a juvenile or adult correctional facility, and/or inclusion in registrations and public notification systems. Approximately one third of sexual offenses against children are committed by adolescents. Sexual offenses against children younger than 12 years tend to be committed by boys aged 12 to 15 years.^122,123 The majority of adolescent sexual offenders are male, accounting for 93% of all juvenile arrests for sex offenses, excluding prostitution.¹²⁴

Parent Education and Clinical Management: Children (Aged 3 to 12 Years)

Concerns about sexual behavior of youth may manifest in a variety of ways in the medical office. During assessment of a wide range of behavior problems, concerns about respect of other’s boundaries and sexual acts may arise. As sexual behavior, particularly in young children, often raises suspicion of sexual abuse, such children’s caregivers may express concern about possible victimization of the child. Families and other professionals may seek advice for follow-up and management once SBPs have been identified.

Parents are generally interested in and expect pediatricians to discuss normal sexuality and sexual abuse prevention.¹⁴³ When there are concerns about SBPs, information provided depends on the results of the initial screening and, if warranted, further evaluation. In determining whether sexual behavior is inappropriate, it is important to consider whether the behavior is common or rare for the child’s developmental stage and culture, the frequency of the behaviors, the extent to which sex and sexual behavior have become a preoccupation for the child, and whether the child responds to normal correction from adults or whether the behavior continues after normal corrective efforts.¹¹⁹ In determining whether the behavior involves potential for harm, it is important to consider the age/developmental differences of the children involved; any use of force, intimidation, or coercion; the presence of any emotional distress in the children involved; whether the behavior appears to be interfering with the children’s social development; and whether the behavior causes physical injury.^9,144,145

Parent education may include information about typical sexual development and how to distinguish SBPs from sex play; specific instructions for reducing exposure to sexually stimulating media or situations in the home; instructions for monitoring interactions with other children; suggestions for how parents should respond to sexualized behaviors; and teaching children rules about privacy, sexual behavior, and boundaries.^119,146

Parents and caregivers often are understandably concerned about the causes of the SBP. In some cases, there appears to be relatively clear sequence of events that explain the development of the SBP (such as young child’s being sexually abused by an uncle, followed by the child’s repeating the behavior with another child at daycare). However, such direct pathways are often not present, inasmuch as causes for human behavior can involve the interplay of multiple factors, and may not be fully knowable.⁸ Parents can be reassured that children with SBPs can be treated successfully without clear evidence of the origins of the behavior, with the exception of situations of ongoing sexual abuse.

Ongoing sexual abuse is of serious concern, both for the child’s welfare and for the success of intervention efforts. Indeed, subsequent sexual abuse appears to increase the likelihood of future SBPs.¹⁰⁵ In cases in which the Child Protective Services investigation of sexual abuse yields inconclusive results, interventions focused on educating children about sexual abuse, identifying whom children may tell if they were being abused, having significant adults support this message, and building support systems around the child have been recommended.⁷³ Repeated questioning and interviewing the child after thorough investigations are not recommended, because they may lead to inaccurate information and have potential deleterious effects on the child.¹¹⁹

Other parental concerns often relate to the misunderstanding about the meaning of childhood SBPs and likelihood of problematic adult sexual behavior, including pedophilia. The results of a 10-year prospective study of children with SBPs indicated low rates of future sexual offenses (2% to 10%, depending on treatment type).¹⁰⁵ A continuation of SBPs from childhood into adolescence and adulthood appears rare. Calm parental responses to these situations are advised.¹⁴⁷ Efficacious treatments have been outpatient and short-term and have involved helping the children while living in their natural environment and while attending school. Restricted environments and treatments should be reserved for children who pose immediate risk because of coercive, aggressive, harmful sexual behavior that has not been readily modifiable with appropriate parental interventions and treatment.⁸

Resources are available to professionals in their work with parents. Fact sheets addressing typical sexual development, SBPs, and common misconceptions about child with SBPs can be found on the Website of the National Center on the Sexual Behavior of Youth (www.ncsby.org). An information booklet on child sexual development and SBPs¹⁴⁵ is useful to supplement education for the caregivers (www.TCavJohn.com). Anticipatory guidelines on issues related to sexual development and behavior throughout childhood and adolescents with information on ways to approach issues of sexual development, sexuality, sexual behavior, and sexual abuse prevention designed for pediatric practice are available.^2,147 In addition, the report from the Task Force on Children with Sexual Behavior Problems of the Association of the Treatment of Sexual Abusers is a useful resource for professionals (www.atsa.org).⁸ This report provides more a detailed review of the research and guidelines on the identification, clinical assessment, treatment, and policy issues relevant to children with SBPs.

Parent Education and Clinical Management: Adolescents (Aged 13 to 17 Years)

Caregivers and referring providers may need support in how to address sexual topics with youth. Furthermore, because of the sensitive and, at times, taboo nature of the topic, cultural considerations and sensitivity are necessary in approaching and educating about sexual matters. Guidelines for pediatricians and family practitioners on assessment and management sexual topics with adolescents and caregivers are available.^2,6,147 Caregivers often require education in addition to the youth. Helpful resources for caregivers can be found at www.advocatesforyouth.org and www.talkingwithkids.org.

When an adolescent is suspected of engaging in illegal sexual behavior, providers need to respond in a manner consistent with the reporting requirements for their state, including reporting suspected illegal sexual behavior with children as indicated. Developmental-behavioral pediatricians can help caregivers and adolescents by referring youths for clinical assessment and efficacious treatment when available.

Unfortunately, efficacious treatment is not available in all areas of the United States. If efficacious treatment is not available, then the developmental-behavioral pediatrician should look for cognitive-behavioral treatment programs that involve both adolescents and caregivers and do not use adult sex offender treatment interventions (e.g., penile plethysmograph, polygraph) that may be inappropriate for adolescents.

Typically, adolescent sexual offenders can be treated in the community in outpatient treatment programs. Most adolescent sexual offenders can remain in the community with appropriate supervision by caregivers and probation officers and can be treated on an outpatient basis.¹³⁵ In general, adolescent sexual offenders who are being treated in the community can attend school and engage in other activities, such as team sports and church. However, a small number of adolescent sexual offenders may need a higher level of care (i.e., residential or custodial placement).

Currently, there is no scientifically supported test to determine which adolescent sexual offenders are at high risk for recidivism. Usually, it is appropriate to treat an adolescent sexual offender as being at low risk for recidivism and in an outpatient setting, unless there is evidence that they are at higher risk. There are clinical guidelines to help identify youths at higher risk in order to help determine the level of care (outpatient vs. residential) that they may require. These factors are important in determining risk: (1) a history of multiple sexual offenses, particularly if sexual offenses continue despite appropriate treatment; (2) a history of multiple nonsexual juvenile offenses; (3) sexual attraction to children; (4) noncompliance with an adolescent sexual offender treatment program; (5) other “self-evident risk signs,” including significant behavior problems and stated intent to commit repeated sexual offenses; and (6) caregivers’ not providing the appropriate and recommended supervision and/or caregivers who are not compliant with treatment or probation.¹²¹

Collaboration with Family and Other Professionals and Agencies (Ages 3 to 17 Years)

As discussed in Chapter 8A, family-centered and collaborative approaches to service delivery are crucial for all children with developmental and behavioral needs. This is particularly true for children with SBPs and adolescent sexual offenders, for whom not only parents and caregivers but also other treatment providers, child welfare workers, schools, child care providers, juvenile justice staff, and court officials are involved in the care. The extent of collaboration and who may need to be included can be expected to vary considerably across cases. Main purposes of coordination and information sharing are to define service goals, articulate a clear plan and timetable of specific tasks needed to reach those goals, identify who on the team is responsible for each aspect of the plan, and evaluate plan implementation and goal attainment.⁸

Homosexuality

The sexual behavior of youth who identify themselves as gay, lesbian, or bisexual or who report homosexual or bisexual experiences are to be assessed with sensitivity and with nonjudgmental response and information. Education and intervention (e.g., information about relationships, decision making, self-care, reproduction, sexually transmitted diseases, protection) similar to that given to heterosexual youths often needs to be provided. In addition, the clinician should also be aware of the increased risk for other problems in homosexual or bisexual youths. These youths may feel extremely isolated from their peers and/or families and may have been the victims of violence and harassment.¹⁴⁸ Nonheterosexual youth are at higher risk for behavioral and emotional problems and risky behaviors, including drug use and abuse, self-harm, school problems, and suicide.^2,149 The American Academy of Pediatrics’ Committee on Adolescence’s clinical report on sexual orientation and adolescents provides useful information and guidelines for the care and support of youths.⁶⁴

Children and Adolescents with Developmental Delays and Disabilities

In addition to the typical topics for sexual education, youths with disabilities may need focused information on ways to express physical affection, with whom, and under what circumstances, with an understanding of the youth’s need for intimacy and affection. Because of the increased risk of sexual abuse of such children, education should include sexual abuse prevention components. Self identity, developing relationships, and intimacy are important areas neglected in many sexual education programs for all youths. Caregivers and providers can be encouraged to provide guidance and education based on individual learning styles and disability-specific challenges, considering the use of visual supports (e.g., pictures, dolls), repeating information over time, and having the youth demonstrate or practice the information learned.^2,67 Issues of consent, marriage, and family planning are complicated and require collaborative care and an understanding of individuals’ desires, choices, capabilities, supports, and needs. Curriculum on sex education for children and youths with disabilities are available¹⁵⁰ (see also the University of South Carolina Center for Disability Resource Library at http://uscm.med.sc.edu/CDR/sexualeducation.htm), as well as other useful information including one from the American Academy of Pediatrics.^67,151

Cultural Factors Affecting Parental Education and Other Service Provision

Consideration of the child and family’s cultural values, beliefs, and norms are of foremost importance in the provision of any mental health and social services. Race, ethnicity, religion, spirituality, socioeconomic factors, and other cultural factors can strongly affect individuals’ and families’ receptivity and response to treatment of child SBPs. Professionals are advised to account for the effect of the specific social ecology experience of the child. Significant variation among children exists, inasmuch as cultural and social context, as well as family attitudes and educational practices, affect children’s knowledge and behavior.^18,19,30

Because of the sensitive nature of the topic, clinicians must become knowledgeable about the family’s and community’s beliefs, values, traditions, and practices concerning sex, including the spoken and unspoken rules about public and private behavior, relationships, intimacy, and modesty. For example, discussions on sexual behavior with children may be considered appropriate for some individuals (e.g., aunts teaching nieces) but taboo for others (e.g., fathers talking with daughters). Provision of education in a manner consistent with the culture and family beliefs are recommended. African-American mothers have been found to integrate story telling in process of providing sex education.¹⁵² Storytelling is also integral for American Indron Alaska Native, and Native Hawaiian families.¹⁵³ Beliefs about the appropriateness of children’s touching their own private parts and about masturbation tend to be strong and directly affect receptiveness to treatment. Understanding and respecting the cultural beliefs and values of families and providing services to enhance the family’s ability to accept and receive the services is crucial not only for outcome but also for initiation and retention of families in services.

Methodological Issues

Conducting research on the sexual knowledge and sexual behavior of children and youth has multiple challenges. Parents who allow their young children to participate in research on sexual knowledge may have distinct values and parenting practices from those who do not allow their children to participate. In one study, researchers noted that the majority of parents approached chose not to have their child participate; the concern about topic reported was the reason for declining.¹⁸ The unknown effect of participation bias limits the generalizability of results.

Much of the research on children’s sexual behavior has relied on caregivers’ or teachers’ reports. Self-reports of sexual behavior from adolescents suggest higher prevalence of sexual behaviors and sexual assaults than has been detected by administrative systems (such as child protective services, juvenile court system). Furthermore, retrospective research with adults suggests that caregivers are often unaware of sexual behavior that occurs among children. Retrospective research, although useful, relies on the memory of the adults, which is affected by a variety of factors. Administrative data sources track only the more severely maladaptive sexual behaviors and are also subjected to a variety of biases. The hidden nature of the sexual behavior of youths, particularly school-aged children and adolescents, challenges direct observations. Direct questioning of children and even adolescents about their sexual behavior is often restricted, particularly in the United States. Thus, reliable and valid information about children and adolescents sexual behavior is difficult to obtain, which further affects researchers’ ability to track and examine factors that affect the trajectory of sexual behaviors.

Examination of treatment efficacy for SBPs of children and adolescent poses additional challenges. Because of the concerns about the ramifications of ongoing SBPs, randomized trials with no treatment or placebo control conditions are generally considered unethical. Quasi-experimental designs and preintervention/postintervention evaluations limit clinicians’ ability to progress in understanding intervention efficacy. Randomly assigning children to receive one of two treatments when both interventions are believed to be efficacious requires a considerable sample size, perhaps multisite studies, to determine differences in effect sizes.

Recommendations for Future Research

Even basic information about SBPs in children and adolescents, such as prevalence and incidence data, is unavailable. National data on the incidence, prevalence, and frequency of types of sexual behaviors in children and youth would greatly enhance the literature. Clear, consistent definitions of types of sexual behaviors are necessary. Furthermore, because no single state or federal agency is designated as responsible for assessing and responding to sexual behavior of youths, the collection of incidence and prevalence data is challenged.

There is considerable research to be done in the area of clinical assessment of children and adolescents with SBPs. The CSBI⁸⁸ is the only norm-based measure of sexual behaviors of youth and is quite useful for clinical assessment, as well as monitoring treatment progress. The published version of the measure does not include items to assess aggressive or coercive sexual behaviors; however, Friedrich evaluated four such items after the published measure.³³ The published norms are based predominately on data from Caucasian and African-American children. Cross-cultural research with normative data from other populations is needed. No norms are available for the accompanying Safety Checklist.³³ The Child Sexual Behavior Checklist⁹⁸ includes items that assess broad issues such as environmental factors, in addition to specifics about the types and other details about SBPs. Although the measure is clinically useful, no norms have yet been published. Research is also needed in how to sensitively and culturally appropriately measure children’s sexual thoughts and understanding of their sexual behaviors.

There is one measure of adolescent sexual behavior: the ACSBI.¹⁴⁰ This is a useful measure for clinically referred adolescents and can help guide treatment. However, there is no normative sample for this measure. The clinical sample used for development was primarily white and of middle to upper middle socioeconomic status. Research on normative sexual behavior of adolescents, including cross-cultural and economically diverse samples, is needed. One important assessment question is estimating the likelihood of sexual and nonsexual repeated offense. Although there are some adolescent sexual offender actuarial systems under development, this is still an area for continued research.

An untapped area of measurement concerns the caregivers’ knowledge of, reaction to, and perception of their child and the sexual acts. Mothers’ emotional reaction and support has been found to mediate treatment outcomes for preschool- and school-aged sexually abused children.^107,154,155 Clinically, caregivers’ perceptions of their children who have demonstrated SBPs appear to strongly affect their willingness to support the child, engage in services, and respond to intervention. Psychometrically supported measures of caregiver’s emotional reaction to, support of, and perceptions for this specific population would facilitate research in this area.

Origins, trajectory, risk factors, and treatment outcome probably vary for subgroups of children and adolescents with SBPs. Typologies have been proposed on the basis of the types of sexual behavior exhibited, as well as other factors (such as gender, comorbid conditions and nonsexual delinquent acts). No clear classification has yet emerged to advance understanding in this area.

Additional research on such service factors as group versus individual/family services, use of direct practice of skills with families in session, and need of specific components of treatment (such as acknowledging past SBPs) would advance the field. Because of the low base rates of subsequent sexual offenses in children,¹⁰⁵ it is unlikely that refined services would significantly lower this rate any further. However, researchers could examine improvements of less severe sexual behaviors, receptivity of services by families, reduced treatment burden, treatment attrition, comorbid symptom relief, and gains in coping skills and resiliency factors.

Research on services in more restrictive settings (i.e., inpatient and residential interventions) for children and adolescents with persistent, aggressive SBPs is limited to clinical descriptions and quasi-experimental designs. These youths are also more likely to have histories of severe trauma, comorbid conditions, and problematic family histories and situations (e.g., mental illness, substance abuse, maltreatment, community and domestic violence).

Many youths with SBPs have comorbid conditions of post-traumatic stress disorder, separation anxiety, and/or disruptive behavior disorders (including oppositional defiant disorder, attention-deficit/hyperactivity disorder, and conduct disorder). Although evidence-based treatments exist for each of these conditions, research on the most efficacious and efficient manner to integrate these services for children with comorbid conditions, in such a way that it is also palatable for families, is needed.

In many ways, the treatment outcome research on children with SBPs is more advanced than the research literature on adolescent and adult sex offender treatment outcomes. Only investigations of multisystemic therapy have amassed any controlled trial data with adolescents. Thus, many treatment questions remain. Comparisons of community-based treatments with residential treatment are particularly important, in view of the possible iatrogenic effects of residential placement.

The results of the prospective studies on children and adolescents with SBPs are encouraging but limited to a few studies focusing on administrative data sources. Longitudinal research integrating administrative data with self- and caregiver-disclosed rates of SBPs, other delinquent acts, victimization, and trauma experiences is warranted. Preschool-aged children with SBPs have been found to have much more frequent SBPs, more severe comorbid conditions, and greater rates of placement disruptions than do school-aged children with SBPs.⁷⁸ Trajectories of nonsexual disruptive behaviors (particularly physical aggression) have been found to be distinct, depending in part on age at onset, wherein a younger onset is related to more severe and pervasive problems (e.g., Broidy et al¹⁵⁶). Longitudinal research with preschool- as well as school-age onset of SBPs would facilitate the examination of whether SBPs have a pattern similar to that of other disruptive behaviors.

In summary, initial results in this relatively new area of research are encouraging, but further research is warranted for prevalence and incidence data, assessment, typology, treatment mediators and outcome, and longitudinal trajectories.

Reliability and Validity

In the clinical research literature, very little attention has been paid to reliability of diagnosis for GID. One study demonstrated that clinicians can reliably make the diagnosis in children²⁵ but, to my knowledge, no investigators have evaluated the reliability of the diagnosis for adolescents.²⁶

It is relatively uncommon, at least in specialized child and adolescent gender identity clinics, to encounter an adolescent who has only very mild gender dysphoria. Thus, it is important to keep in mind that the indicators of GID are meant to capture a “strong and persistent cross-gender identification” and a “persistent discomfort” with one’s gender, not transient feelings.^27–28

The DSM-IV-TR criterion with regard to the “preoccupation” with primary and secondary sex characteristics (Point B-2) reflects well the adolescent expression of gender dysphoria as it pertains to discomfort with somatic sex, inasmuch as the distress over physical sex markers is so pervasive (Table 25B-2).

TABLE 25B-2 DSM-IV-TR Diagnostic Criteria for Gender Identity Disorder

From the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision [DSM-IV-TR]. Washington, DC: American Psychiatric Press, 2000.

As noted previously, there is only one clinician-based reliability study of GID in children; however, there is a much more extensive literature in which its discriminant validity has been examined. Since the early 1970s, a variety of measurement approaches have been developed to assess the sex-typed behavior in children referred clinically for GID, including observation of sex-typed behavior in free play tasks, on semiprojective or projective tasks, and on a structured Gender Identity Interview schedule. In addition, several parent-report questionnaires pertaining to various aspects of sex-typed behavior have been developed. In this line of research, several comparison groups have typically been used: siblings of children with GID, clinical controls, and nonreferred (or “normal”) controls.^29–31

The results of these studies have demonstrated strong evidence for the discriminant validity of the various measures, with large effect sizes.²⁹ In addition, several studies have shown that gender-referred children can be distinguished as a function of whether they met the complete DSM-IV-TR criteria for GID (i.e., threshold vs. subthreshold cases).^31–35

Two self-report and one parent report instruments are described. All three of these measures have practical utility in an office-based practice and can complement a detailed clinical interview. The first is the Gender Identity Interview for Children, which contains 11 items. Each item is coded on a 3-point response scale. On the basis of factor analysis, Zucker and associates³² identified two factors, which were labeled affective gender confusion (seven items) and cognitive gender confusion (four items) and accounted for 38.2% and 9.8% of the variance, respectively. An item example from the first factor is “In your mind, do you ever think that you would like to be a girl (boy)?” and an item example from the second factor is “Are you a boy or a girl?” Both mean factor scores significantly differentiated gender-referred probands (n = 85) from controls (n = 98). Cutoff scores of either three or four deviant responses yielded high specificity rates (88.8% and 93.9%, respectively), but lower sensitivity rates (54.1% and 65.8%, respectively).

The second instrument is the Gender Identity Questionnaire for Children, a parent-report questionnaire.^33–34 This questionnaire consists of 16 items pertaining to various aspects of sex-typed behavior that are reflected in the GID diagnostic criteria, each rated on a 5-point response scale. A factor analysis based on 325 gender-referred children and 504 controls (siblings, clinic-referred, and nonreferred), with a mean age of 7.6 years, identified a one-factor solution containing 14 items, accounting for 43.7% of the variance. The gender-referred children had a significantly more total deviant score than did the controls, with a large effect size of 3.70, established by Cohen’s d. With a specificity rate set at 95% for the controls, the sensitivity rate for the probands was 86.8%.

The third instrument is the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDQ-AA), another self-report questionnaire.³⁶ The GIDQ-AA consists of 27 items pertaining to various aspects of gender dysphoria, each rated on a 5-point response scale and with the past 12 months used as a time frame. In the female version, for example, items included: “In the past 12 months, have you felt more like a man than like a woman?” and “In the past 12 months, have you wished to have an operation to change your body into a man’s (e.g., to have your breasts removed or to have a penis made)?” A factor analysis based on 389 university students (heterosexual and nonheterosexual) and 73 clinic-referred patients with GID identified a one-factor solution containing all 27 items, which accounted for 61.3% of the variance. The GIDQ-AA strongly distinguished the GID patients from both the heterosexual and nonheterosexual controls. With a cutpoint of 3.00, sensitivity was 90.4% for the patients with GID, and specificity was 99.7% for the controls.

Associated Behavior Problems

A considerable amount of evidence suggests that in the presence of GID symptoms, it is important to assess for the presence of behavior problems. The most systematic information on general behavior problems in children with GID comes from parent-report data on the CBCL. On the CBCL, clinic-referred boys and girls with GID display, on average, significantly more general behavior problems than do their siblings and nonreferred children^22,31 and levels comparable to those of demographically matched clinical controls³¹; moreover, CBCL-identified behavior problems are significantly more prevalent among adolescents with GID than among their GID child counterparts.^23,26

According to the CBCL responses, boys with GID have a predominance of internalizing behavioral difficulties, whereas girls with GID do not.³¹ Two studies have shown that boys with GID demonstrate high rates of separation anxiety traits.^37,38 Several studies have shown that increasing age was significantly associated with degree of behavior problems in boys with GID, which is probably mediated by peer ostracism,^20,22,31 and another study has shown that a composite index of maternal psychopathology was also a strong predictor of behavior problems.³⁹

Follow-up Studies of Boys

Green’s study⁴¹ constitutes the most comprehensive long-term follow-up of behaviorally feminine boys, the majority of whom would likely have met DSM-IV-TR criteria for GID. His study contained 66 feminine and 56 control boys (unselected for gender identity) assessed initially at a mean age of 7.1 years (range, 4 to 12). Forty-four feminine boys and 30 control boys were available for follow-up at a mean age of 18.9 years (range, 14 to 24). The majority of the boys were not in therapy between assessment and follow-up. Sexual orientation in fantasy and behavior was assessed by means of a semistructured interview. Kinsey ratings were made on a 7-point continuum, ranging from exclusive heterosexuality (a Kinsey rating of 0) to exclusive homosexuality (a Kinsey rating of 6).⁴² Depending on the measure (fantasy or behavior), 75% to 80% of the previously feminine boys were either bisexual or homosexual (Kinsey ratings between 2 and 6) at follow-up, in contrast to 0% to 4% of the control boys. Green also reported on the gender identity status of the 44 previously feminine boys. He found that only one youth, at the age of 18 years, was gender-dysphoric to the extent of considering sex-reassignment surgery.

Data from six other follow-up reports on 55 boys with GID were summarized by Zucker and Bradley.³¹ In these studies, the percentage of boys who exhibited persistent GID was higher than that reported by Green (11.9% vs. 2.2%, respectively), but the percentage who were homosexual (62.1%) was somewhat lower.

Zucker and Bradley³¹ reported preliminary follow-up data on a sample of 40 boys first observed in childhood (mean age at assessment, 8.2 years; range, 3 to 12). At follow-up, these boys were, on average, 16.5 years old (range, 14 to 23). Gender identity was assessed by means of a semistructured clinical interview and by questionnaire. Sexual orientation (for a 12-month period before the time of evaluation) was assessed for fantasy and behavior with the Kinsey scale in a manner identical to Green’s study.⁴¹

Of the 40 boys, 8 (20%) were classified as gender-dysphoric at follow-up. With regard to sexual orientation in fantasy, 20 (50%) were classified as heterosexual, 17 (42.5%) were classified as bisexual/homosexual, and 3 (7.5%) were classified as “asexual” (i.e., they did not report any sexual fantasies). Regarding sexual orientation in behavior, 9 (22.5%) were classified as heterosexual, 11 (27.5%) were classified as bisexual/homosexual, and 20 (50.0%) were classified as “asexual” (i.e., they did not report any interpersonal sexual experiences).

Cohen-Kettenis⁴³ reported preliminary data on a sample of 56 boys first observed in childhood (mean age at assessment, 9 years; range, 6 to 12) and who had now reached adolescence. Of these, 9 (16.1%) requested sex-reassignment, and all 9 had a homosexual sexual orientation (P. T. Cohen-Kettenis, personal communication, February 1, 2003). Thus, the rate of GID persistence, at least into adolescence, was higher than that reported by Green⁴¹ and comparable to the rate obtained by Zucker and Bradley,³¹ as noted previously.

Follow-up Studies of Girls

To date, the most systematic follow-up of girls with GID was conducted by Drummond⁴⁴ of patients seen in my clinic. A total of 25 girls, originally assessed at a mean age of 8.8 years (range, 3 to 12), were interviewed at follow-up at a mean age of 23.2 years (range, 15 to 36). Of these 25 girls, 3 (12%) had persistent GID (at follow-up ages of 17, 21, and 23 years), of whom 2 had a homosexual sexual orientation and 1 was “asexual” (i.e., did not report any sexual orientation). The remaining 22 girls (88%) had a “normal” gender identity.

With regard to sexual orientation in fantasy (Kinsey ratings) for the 12 months preceding the follow-up assessment, 15 (60%) girls were classified as exclusively heterosexual, 8 (32%) were classified as bisexual/homosexual, and 2 (8%) were classified as “asexual” (i.e., did not report any sexual fantasies). Regarding sexual orientation in behavior, 11 (44%) girls were classified as exclusively heterosexual, 6 (24%) were classified as bisexual/homosexual, and 8 (32%) were classified as “asexual” (i.e., they did not report any interpersonal sexual experiences).

In another study, Cohen-Kettenis⁴³ reported preliminary data from a sample of 18 girls first seen in childhood (mean age at assessment, 9 years; range, 6 to 12) and who had now reached adolescence. Of these, 8 (44.4%) requested sex reassignment, and all had a homosexual orientation (P. T. Cohen-Kettenis, personal communication, February 1, 2003). Thus, the rate of GID persistence, at least into adolescence, was high (and much higher than the rate of persistence for the boys with GID).

Summary

In taking stock of these outcome data, Green’s⁴¹ study clearly showed that boys with GID were disproportionately, and substantially, more likely than the control boys to differentiate a bisexual/homosexual orientation. The other follow-up studies yielded somewhat lower estimates of a bisexual/homosexual orientation. In this regard, at least one caveat is in order. In Zucker and Bradley’s³¹ follow-up, for example, the boys were somewhat younger than were the boys in Green’s follow-up; thus, their lower rate of a bisexual/homosexual orientation outcome should be interpreted cautiously, inasmuch as, if anything, these youth would be expected to underreport an atypical sexual orientation because of social desirability considerations. But even these lower rates of a bisexual/homosexual orientation are substantially higher than the currently acknowledged base rate of about 2% to 3% of men with a homosexual orientation that has been identified in epidemiological studies.¹³ A similar conclusion can be drawn with regard to girls with GID. Using prevalence estimates of bisexuality/homosexuality in fantasy among biological females (anywhere between 2% and 5%), Drummond⁴⁴ reported that the odds of reporting bisexuality/homosexuality in fantasy was 8.9 to 23.1 times higher than in the general population. The odds of reporting bisexuality/homosexuality in behavior was 6.7 to 15.5 times higher than in the general population.

A more substantive difference between Green’s⁴¹ study and the other follow-up reports of boys pertains to the persistence of gender dysphoria. Both Zucker and Bradley³¹ and Cohen-Kettenis,⁴³ for example, found higher rates of persistence than did Green. At present, the reasons for this are unclear. One possible explanation pertains to sampling differences. Green’s study was carried out in the context of an advertised research study, whereas Zucker and Bradley’s and Cohen-Kettenis’s samples were clinic-referred. Thus, it is conceivable that their samples may have included more extreme cases of childhood GID than did the sample ascertained by Green.

With regard to girls with GID, the odds of persistent gender dysphoria in Drummond’s⁴⁴ sample was 4084 times the odds of gender dysphoria in the general population.¹⁶

Biological Mechanisms

Contemporary biological research on human psychosexual differentiation includes investigations of molecular genetics, behavioral genetics, prenatal sex hormones, prenatal maternal stress, maternal immunization, neurodevelopmental processes, pheromones, temperament, anthropometrics, and neuroanatomical substrates. Some of these parameters have been studied with regard to both children and adults with GID, some have been investigated in relation to sexual orientation, and others have been examined in nonclinic populations (e.g., twin studies).

Experimental studies—from mice to monkeys—have shown quite clearly how manipulation of the prenatal hormonal milieu can affect postnatal sex-dimorphic behavior.⁴⁸ In humans, the effects of the prenatal hormonal environment have been examined in various physical intersex conditions. Consider, for example, studies of congenital adrenal hyperplasia (CAH), the most common physical intersex condition that affects genetically female humans. CAH is an autosomal recessive disorder associated with enzyme defects that result in abnormal adrenal steroid biosynthesis. Indeed, for affected genetically female fetuses, testosterone assayed from amniotic fluid during midgestation shows values in the range of unaffected genetically male fetuses. Because of this high level of androgen production during fetal development, masculinization of the external genitalia is common. On the basis of data from lower animals and on theory, it has been presumed that some masculinization of the fetal brain may also have occurred.

There is very clear evidence that the gender role behavior of girls with CAH is more masculine and/or less feminine than that of unaffected control girls.^29,49 Moreover, adult follow-up studies of girls with CAH indicate that they have higher rates of bisexuality and homosexuality (particularly in fantasy) than do controls. Thus, for both gender role behavior and sexual orientation, there is a shift away from the female-typical pattern and toward the male-typical pattern. The evidence that CAH results in an altered gender identity is much less convincing. Although the percentage of genetically female girls with CAH—about 5%—who develop gender dysphoria or change gender from female to male is higher than that of girls in the general population, most girls and women with CAH appear to have an uncomplicated female gender identity.⁵⁰ Together, these findings suggest that the prenatal hormonal milieu may have a greater effect on gender role and sexual orientation than it does on gender identity in girls and women with CAH.

As applied to GID (in both children and adults), classical prenatal hormone theory has, at least in its simple form, been challenged because there is no compelling evidence that the prenatal hormonal milieu is grossly abnormal because the differentiation of the external genitalia is normal. Thus, at least in terms of gross markers of biological sex, it appears that most individuals with GID are somatically normal.⁵¹ This has led some researchers to consider alternative biological pathways that might affect psychosexual differentiation or to reconsider prenatal hormone theory in terms of behavioral-genital dissociations: that is, hormonal effects on the brain but not the genitals. Such researchers have has examined behavior genetics (the liability for cross-gender behavior),^21,52 altered ratio of the length of the second digit to that of the fourth digit,⁵³ handedness,^54,55 sibling sex ratio and birth order,^56–58 and neuroanatomical substrates.^59,60 This line of research reviewed has begun to identify some characteristics of children and adults with GID that may well have a biological basis. In some respects, however, it has been easier to rule out candidate biological explanations, such as the influence of gross anomalies in prenatal hormonal exposure.^61–62 Nonetheless, the study of new potential biological markers of variation in psychosexual differentiation has opened up avenues for novel empirical inquiry that will probably be pursued in the years to come.

Psychosocial Mechanisms

Psychosocial factors, to truly merit causal status, must be shown to influence the emergence of marked cross-gender behavior in the first few years of life. Otherwise, such factors are better conceptualized as perpetuating rather than predisposing. A few of the more prominent hypotheses and relevant data are discussed as follows.

Ethical Considerations

Consider the following clinical scenarios:

Any contemporary pediatric clinician responsible for the therapeutic care of children and adolescents with GID is quickly introduced to complex social and ethical issues pertaining to the politics of sex and gender in post-modern Western culture and will have to think them through carefully. The scenarios just described, as well as many others, require the clinician to think long and hard about theoretical, ethical, and treatment issues.

Treatment of Children

Elsewhere, I have identified five rationales for intervention in the treatment literature on children with GID: (1) reduction in social ostracism, (2) treatment of underlying psychopathology, (3) treatment of the underlying distress, (4) prevention of transsexualism in adulthood, and (5) prevention of homosexuality in adulthood.⁶⁷

In my view, the first four rationales are clinically defensible, but the fifth is not. Therefore, on this last point, further explication is warranted. Some critics have argued that clinicians consciously or unconsciously accept the prevention of homosexuality as a legitimate therapeutic goal.⁶⁸ Others have asserted, albeit without empirical documentation, that treatment of GID results in harm to children who are “homosexual” or “prehomosexual.”⁶⁹

The various issues regarding the relation between GID and homosexuality are complex, both clinically and ethically. Three points, although brief, can be made. First, until it has been shown that any form of treatment for GID during childhood affects later sexual orientation, Green’s⁴¹ discussion of whether parents have the right to seek treatment to maximize the likelihood of their child becoming heterosexual is moot. From an ethical standpoint, however, the treating clinician has an obligation to inform parents about the state of the empirical database. Second, I have argued elsewhere that some critics incorrectly conflate gender identity and sexual orientation, regarding them as isomorphic phenomena, as do some parents.⁷⁰ In psychoeducational work with parents, clinicians can review the various explanatory models regarding the statistical linkage between gender identity and sexual orientation⁷¹ but also discuss their distinctness as psychological constructs. Third, many contemporary pediatric clinicians emphasize that the primary goal of treatment with children with GID is to resolve the conflicts that are associated with the disorder, regardless of the child’s eventual sexual orientation.

If the clinician is to provide treatment for a child with GID, it is important to bear in mind that there has been no single randomized controlled treatment trial. The practitioner must rely largely on the “clinical wisdom” that has accumulated in the case report literature and the conceptual underpinnings that inform the various approaches to intervention.

Behavior Therapy

The literature contains 13 single-case reports in which investigators employed a behavior therapy approach to the treatment of GID in children.^67,71 The classical behavioral approach is to assume that children learn sex-typed behaviors much as they learn any other behaviors and that sex-typed behaviors can be shaped, at least initially, by encouraging some and discouraging others. Accordingly, behavior therapy for GID systematically arranges to have rewards follow gender-typical behaviors and to have no rewards (or perhaps punishments) follow cross-gender behaviors.

One type of intervention employed has been termed differential social attention or social reinforcement. This type of intervention has been applied in clinic settings, particularly to sex-typed play behaviors. The therapist first establishes with baseline measures that the child prefers playing with cross-sex toys or dress-up apparel rather than same-sex toys or dress-up apparel. A parent or stranger is then introduced into the playroom and instructed to attend to the child’s same-sex play (e.g., by looking, smiling, and verbal praise) and to ignore the child’s cross-sex play (e.g., by looking away and pretending to read). Such adult responses seem to elicit rather sharp changes in play behavior.

The field of behavior therapy has produced no new case reports since the 1980s, although its principles are often used in broader treatment approaches that involve the parents. This publication gap is odd, because more contemporary behavioral approaches, such as cognitive-behavior therapy, are now used so widely with other disorders.

Behavior therapy with an emphasis on the child’s cognitive structures regarding gender could be an interesting and novel approach to treatment. There is now a fairly large literature on the development of cognitive gender schemas in nonreferred children.⁶⁵ It is possible that children with GID have more elaborately developed cross-gender schemas than same-gender schemas and that more positive affective appraisals are differentiated for the latter than for the former (e.g., in boys, “Girls get to wear prettier clothes” vs. “Boys are too rough”). A cognitive approach to treatment might help children with GID to develop more flexible and realistic notions about gender-related traits (e.g., “Boys can wear pretty cool clothes, too” or “There are lots of boys who don’t like to be rough”), which may result in more positive gender feelings about being a boy or being a girl.

Psychotherapy

There is a large case report literature on the treatment of children with GID through psychoanalysis, psychoanalytic psychotherapy, or psychotherapy, some reports of which are quite detailed and rich in content.^67,71 The psychoanalytic treatment literature is more diverse than the behavior therapy literature, including varied theoretical approaches to understanding the putative cause of GID (e.g., classical, object relations, and self psychology); nevertheless, a number of recurring themes can be gleaned from this case report literature.

Psychoanalytic clinicians generally emphasize that the cross-gender behavior emerges during the “pre-oedipal” years;⁶⁶ accordingly, they stress the importance of understanding how the GID relates to other developmental phenomena salient during these years (e.g., attachment relations and the emergence of the autonomous self). Oedipal issues are also deemed important, but these are understood within the context of prior developmental interferences and conflicts. Psychoanalytic clinicians also place great weight on the child’s overall adaptive functioning, which they view as critical in determining the therapeutic approach to the specific referral problem.

Apart from the general developmental perspective inherent to a psychoanalytic understanding of psychopathology, there is also a gender-specific perspective on development.⁷ Many developmental psychologists, for example, note that the first signs of normative gender development appear during the toddler years, including the ability to correctly self-label as a boy or a girl. Thus, early gender identity formation intersects quite neatly with analytical views on the early development of the sense of self in more global terms. It is likely, therefore, that the putative pathogenic mechanisms identified in the development of GID are likely to have a greater effect only if they occur during the alleged sensitive period for gender identity formation.⁶¹

An overall examination of the available case reports suggests that psychotherapy, like behavior therapy, does have some beneficial influence on the sex-typed behavior of children with GID. However, the effectiveness of psychoanalytic psychotherapy, like that of behavior therapy, has never been demonstrated in an outcome study comparing children randomly assigned to treated and untreated conditions. Moreover, many of the cases cited previously did not consist solely of psychoanalytic treatment of the child. The parents were often also in therapy, and, in some of the cases, the child was an inpatient and thus exposed to other interventions. It is impossible to disentangle these other potential therapeutic influences from the effect of the psychotherapy alone.

Treatment for the Parents

Two rationales have been offered for parental involvement in treatment. The first emphasizes the hypothesized role of parental dynamics and psychopathology in the genesis or maintenance of the disorder. According to this perspective, individual therapy with the child probably proceeds more smoothly and quickly if the parents are able to gain some insight into their own contribution to their child’s difficulties. Many clinicians who have worked extensively with gender-disturbed children subscribe to this rationale.^72,73,74 Assessment of psychopathology and the marital relationship in the parents of children with GID reveals great variability in adaptive functioning, which may well prove to be a prognostic factor.^31,39

In addition, parents benefit from regular, formalized contact with the therapist to discuss day-to-day management issues that arise in carrying out the overall therapeutic plan. Work with parents can focus on the setting of limits with regard to cross-gender behavior, such as cross-dressing, cross-gender role and fantasy play, and cross-gender toy play and, at the same time, attempting to provide alternative activities (e.g., encouragement of same-sex peer relations and involvement in more gender-typical and neutral activities). In addition, parents can work on conveying to their child that they are trying to help him or her feel better about being a boy or a girl and that they want their child to be happier in this regard. Some parents, especially the well-functioning and intellectually sophisticated ones, are able to carry out these recommendations relatively easily and without ambivalence. Many parents, however, require ongoing support in implementing the recommendations, perhaps because of their own ambivalence and reservations about gender identity issues.⁷¹

Supportive Treatments

Clinicians critical of conceptualizing marked cross-gender behavior in children as a disorder have provided a dissenting perspective to the treatment approaches described so far.^75–77 These clinicians conceptualize GID or pervasive gender-variant behavior from an essentialist perspective—that it is fully constitutional or congenital in origin—and are skeptical about the role of psychosocial or psychodynamic factors. As an example of this perspective, Bockting and Ehrbar⁷⁸ argued that “instead of attempts to change the child’s gender identity or role, treatment should assist the family to accept the child’s authentic gender identity and affirm a gender role expression that is most comfortable for that child” (p 128). Along similar lines, Menvielle and Tuerk⁷⁵ noted that although it might be helpful to set limits on pervasive cross-gender behaviors that may contribute to social ostracism, their primary treatment goal (offered in the context of a parent support group) was “not at changing the children’s behavior, but at helping parents to be supportive and to maximize opportunities for the children’s adjustment” (p 1010). Menvielle and associates⁷⁶ took a somewhat stronger position, by arguing that “Therapists who advocate changing gender-variant behaviors should be avoided” (p 45).

Because comparative treatment approaches are not available, it is not possible to say whether this supportive or “cross-gender affirming” approach will result in both short-term and long-term outcomes any different from the more traditional approaches to treatment. The supportive approach does, however, highlight a variety of theoretical and clinical disagreements, which will be resolved only by more systematic research on therapeutics.

Adolescents

In adolescents with GID, there are three broad clinical issues that require evaluation: (1) the phenomena pertaining to the GID itself, (2) sexual orientation, and (3) psychiatric comorbidity. Gender-dysphoric adolescents with a childhood onset of cross-gender behavior typically have a homosexual orientation (i.e., they are attracted to members of their own “birth sex”). Some such adolescents may not report any sexual feelings, but follow-up typically reveals the emergence of same-sex attractions. Thus, the clinician must evaluate simultaneously two dimensions of the patient’s psychosexual development: current gender identity and current sexual orientation.

The psychotherapy treatment literature on adolescents with GID has been very poorly developed and is confined to a few case reports.^31,67,71 In general, the prognosis for adolescents in resolving the GID is more guarded than it is for children. This state of affairs is similar to that of other child psychiatric disorders: The longer a disorder persists, the less is the likelihood that it will remit, with or without treatment. From a clinical management point of view, two key issues need to be considered: (1) Some adolescents with GID are not particularly good candidates for psychotherapy because of comorbid disorders and general life circumstances, and (2) some adolescents with GID have little interest in psychologically oriented treatment and are quite adamant about proceeding with hormonal and surgical sex reassignment.

Before recommending hormonal and surgical interventions, many clinicians encourage adolescents with GID to consider alternatives to this invasive and expensive treatment. One area of inquiry can, therefore, explore the meaning behind the adolescent’s desire for sex reassignment and whether there are viable alternative lifestyle adaptations. The most common area of exploration in this regard pertains to the patient’s sexual orientation. Some adolescents with GID recall that they always felt uncomfortable growing up as boys or as girls but that the idea of “sex change” did not occur until they became aware of homoerotic attractions. For some of these youngsters, the idea that they might be gay or homosexual is abhorrent (internalized homophobia).

For some such adolescents, psychoeducational work can explore their attitudes and feelings about homosexuality. Youth support groups or group therapy may provide an opportunity for youngsters to meet gay adolescents and can be a useful intervention. In some cases, the gender dysphoria may resolve, and a homosexual adaptation ensues.

For adolescents with persistent gender dysphoria, there is considerable evidence that it often interferes with general social adaptation, including general psychiatric impairment, conflicted family relations, and dropping out of school. For these youngsters, therefore, the treating clinician can consider two main options: (1) supportive management until the adolescent turns 18 and can be referred to an adult gender identity clinic or (2) “early” institution of contrasex hormonal treatment.

An option for treatment of gender-dysphoric adolescents is to prescribe puberty-blocking luteinizing hormone–release agonists (e.g., depot leuprolide or depot triptorelin) that facilitate more successful passing as the opposite sex.⁷⁹ Such medication can suppress the development of secondary sex characteristics, such as facial hair growth and voice deepening in adolescent boys, which make it more difficult to pass in the female social role. Cohen-Kettenis and van Goozen⁴⁶ reported that early cross-sex hormone treatment for adolescents younger than 18 years facilitated the complex psychosexual and psychosocial transition to living as a member of the opposite sex and resulted in a lessening of the gender dysphoria (see also Smith et al⁴⁷). Although such early hormonal treatment remains controversial,⁸⁰ it may be the treatment of choice once the clinician is confident that other options have been exhausted.^26,81

Summary

The treatment literature on GID in children and adolescents has many gaps. As reviewed previously, the literature for children has been confined to a lot of case reports from varying theoretical perspectives, with little in the way of comparative evaluation. Clinicians have varied perspectives on what to treat, and thus the developmental-behavioral pediatrician needs to be aware of the complex ideological, political, and theoretical perspectives that underlie the different positions. For adolescents, there is an emerging consensus by clinicians who work with gender-dysphoric adolescents that cross-sex hormone treatment may well be a reasonable early therapeutic intervention once it becomes clear that psychosocial approaches have not resulted in a reduction of the gender dysphoria.⁸² For both children and adolescents, it is advisable, in my view, that referrals be made to clinicians with a strong background in child and adolescent developmental psychopathology and, when feasible, to therapists with at least some familiarity with the literature on both normative and applied gender development.

Early Childhood: Infants, Toddlers, and Preschoolers (Aged 0 to 6 years)

School-Aged Children (Aged 7 to 12 Years)

Adolescent Sexual Development (Ages 13 to 19 Years)

Cultural Factors Affecting Sexual Development and Behavior

Children’s public and private sexual behavior, modesty, intimacy, and relationships are affected by their family’s and communities’ cultural values, beliefs, norms, religion, spirituality, socioeconomic, historical, and other factors. For example, social environments with norms in which nudity is acceptable, privacy is not reinforced, and exposure to sexualized material is common have been found to be related to higher frequencies of sexual behaviors in the children than are social environments that reinforce modesty and privacy.²⁸

Parents’ attitudes toward children’s sexuality have been found to affect children’s sexual knowledge and behavior.¹⁹ Cultural beliefs may explain normative differences found in cross-cultural studies. For example, mothers of Dutch children report greater frequencies of sexual behaviors in their preschool-aged children than do mothers of American children, which may be related to a more permissive, positive attitude about sexuality and nudity in The Netherlands than in the United States.³⁰ Cultural differences in children’s sexual knowledge (such as physiological distinctions between sexes, pregnancy, and birth) have also been found. For example, preschool-aged girls in the Western hemisphere have been found to perceive that babies were always in their mother’s bellies, whereas Asian boys thought the baby was swallowed.¹⁶

Factors may interact, and differences in regard to norms between boys and girls are not uncommon. Implicit and explicit messages about sexual behavior are provided to children and youths through family, friends, neighbors, and the community, as well as a variety of media (including television, movies, music videos, music lyrics, video games, magazines, the Internet, and communications with cell phones). How children sort out the multiple and often conflicting messages about sex, sexuality, and relationships are not clearly understood. However, reduced risk-related behaviors have been found with attentive parenting with close supervision and good communication. Entertainment television can also have a positive effect on youth knowledge, particularly when paired with good communication with parents.⁶³ Ways in which culture may affect educational and intervention approaches are discussed later in the section on intervention.

Homosexuality

Homosexuality does not begin during adolescence. However, adolescence is the most likely time during childhood that concerns about sexuality, sexual orientation, and sexual behavior are presented to the developmental-behavioral pediatrician.

Many youths experiment with and explore a range of sexual behaviors, including sexual behavior with people of the same and opposite sex.^2,49 Sexual exploration and behavior are not synonymous with sexual orientation.⁶⁴ With whom youths have sexual behavior may be more strongly related to who is regularly in their social environment than with sexual orientation. Adolescents with homosexual experiences may identify themselves as having a heterosexual orientation. Furthermore, adolescents with no sexual experience or only heterosexual experiences may identify themselves as homosexual or bisexual.⁴⁹

National data suggest that 2.3% of men and 1.3% of women in the United States are self-identified as homosexual.⁶⁰ In the same survey, 1.8% of men and 2.8% of women described themselves as bisexual.⁶⁰ Accurate prevalence rates are difficult to calculate because of the continuing stigmatization of homosexuality.⁶⁴ In a survey of junior and high school students from Minnesota, approximately 88% self-identified as heterosexual, 1.6% of boys and 0.9% of girls identified themselves as either primarily homosexual or bisexual, and more than 10% were “not sure” of their sexual orientation.⁶⁵ More information on homosexuality and development is available in Chapter 25C.

Children and Adolescents with Developmental Delays and Disabilities

Sexual development can be more variable when children and youth have developmental delays or disabilities or chronic medical conditions. Developmental disabilities and medical conditions may be associated with precocious or early-onset puberty (e.g., Down syndrome, traumatic brain injuries, and tumors, including hamartoma), delayed puberty (e.g., Prader-Willi syndrome), or disrupted sexual development (e.g., spinal cord injuries).^3,66,67 Historically, professionals and family members have inadequately understood, accepted, and responded to sexual development in individuals with disabilities.^3,67 However, as in all children, sexual arousal and sexual behaviors begins at or around birth, pubertal development with the associated sexual feelings typically occurs, and many adolescents with developmental disabilities date and are sexually active.⁶⁸ Unfortunately, many youths with developmental disabilities have not been provided developmentally appropriate sexual education.^67,69 Providing sex education for children with developmental delays is discussed in the section on recommendations concerning clinical care later in this chapter.

Effect of Sexual Abuse on Childhood Sexual Knowledge and Behavior

Sexual abuse affects children’s sexual knowledge, as well as their sexual behavior. Furthermore, sexually abused children have been found to have greater frequencies of a wide range of sexual behaviors in comparison with normative samples and with children who were clinically referred with no known history of sexual abuse.^28,70,71 Sexually abused preschool-aged children are at greater risk for inappropriate sexual behaviors (35%) than are sexually abused school-aged children (6%).⁷⁰

Although most sexually abused children do not demonstrate SBPs, the presence of SBPs raises concern about child sexual abuse and exposure to sexual material. Professionals need to be well aware of the child abuse reporting statutes in their jurisdiction, because reports of suspected sexual abuse may be necessary. Specific sexual behaviors (such as playing with dolls imitating explicit sexual acts and inserting objects in their own vaginas or rectums) are more likely to occur in children who have been sexually abused than in those who do not have a suspected history.^27,30,72 The presence of sexual behavior maybe enough to suspect sexual abuse and report to authorities for investigation; however, sexual behavior itself cannot be a sole determining factor for diagnosing sexual abuse.⁸ Confirming sexual abuse in young children is quite complex, because often there is no physical evidence and no witnesses, and aspects of the abuse (e.g., threats by the perpetrator) hamper clear reporting by the child.⁷³ Additional information on identification and reporting of and response to suspected sexual abuse is provided in The APSAC Handbook on Child Maltreatment (2ed) by Myers JEB, Berliner L, Briere J et al, 2002.

Problematic Sexual Behavior during Childhood (Ages 3 to 12 Years)

Sexual behavior in childhood occurs on a continuum from typical to concerning to problematic.⁷⁴ SBPs do not represent a medical/psychological syndrome or a specific diagnosable disorder; rather, they represent a set of behaviors that are well outside acceptable societal limits.⁸ SBPs in this context are defined as child-initiated behaviors that involve sexual body parts (i.e., genitals, anus, buttocks, or breasts) and are developmentally inappropriate or potentially harmful to themselves or others.¹ SBPs may range from problematic self-stimulation (causing physical harm or damage) to nonintrusive behaviors (such as preoccupation with nudity, looking at others) to sexual interactions with other children that include behaviors more explicit than sexual play (such as intercourse) to coercive or aggressive sexual behaviors (of most concern, particularly when paired with large age differences between children).

Although the term sexual is used, the intentions and motivations for these behaviors may not be related to sexual gratification or sexual stimulation. Rather, the behaviors may be related to curiosity, anxiety, reenacting trauma, imitation, attention-seeking, self-calming, or other reasons.¹

Children as young as 3 and 4 years of age with SBPs have been described in the literature.^75–78 Girls may be somewhat more likely than boys to be referred for services for SBPs during preschool years⁷⁸ and boys during the school years.^79,80 However, no population-based statistics on the incidence or prevalence of SBPs in children are available. By definition, most of the sexual behaviors involved are fairly rare.²⁸ Since the 1980s, there has been an increase in the number of children with SBPs who have been referred for child protective services, juvenile services, and treatment in both outpatient and inpatient settings.⁸¹ The increase in referrals may represent an actual increase incidence of such behaviors, changing definitions of problematic sexual behavior, improved awareness and reporting of what has always existed, or some combination of these factors.⁸

The prevalence of sexual behavior for specific races, ethnic groups, religious groups, and socioeconomic groups is unknown. In groups in which there are extremely high rates of sexual abuse at a young age, the children are at higher risk for developing problematic sexual behaviors.

Problematic Sexual Behavior during Adolescence

Adolescent sexual offenders are adolescents between the ages of 13 and 17 years who commit sexual behavior that is illegal as defined by the sex crime statutes of the jurisdiction in which the offense occurred.¹²¹ In general, the legal system (i.e., family or juvenile court, probation officer, judge, district attorney) is involved when an adolescent commits a sexual crime, because of the adolescent’s assumed culpability in committing the crime. The response of the legal system to an adolescent’s sexual crime varies greatly by state and may include court-ordered treatment, probation, imprisonment in a juvenile or adult correctional facility, and/or inclusion in registrations and public notification systems. Approximately one third of sexual offenses against children are committed by adolescents. Sexual offenses against children younger than 12 years tend to be committed by boys aged 12 to 15 years.^122,123 The majority of adolescent sexual offenders are male, accounting for 93% of all juvenile arrests for sex offenses, excluding prostitution.¹²⁴

Parent Education and Clinical Management: Children (Aged 3 to 12 Years)

Concerns about sexual behavior of youth may manifest in a variety of ways in the medical office. During assessment of a wide range of behavior problems, concerns about respect of other’s boundaries and sexual acts may arise. As sexual behavior, particularly in young children, often raises suspicion of sexual abuse, such children’s caregivers may express concern about possible victimization of the child. Families and other professionals may seek advice for follow-up and management once SBPs have been identified.

Parents are generally interested in and expect pediatricians to discuss normal sexuality and sexual abuse prevention.¹⁴³ When there are concerns about SBPs, information provided depends on the results of the initial screening and, if warranted, further evaluation. In determining whether sexual behavior is inappropriate, it is important to consider whether the behavior is common or rare for the child’s developmental stage and culture, the frequency of the behaviors, the extent to which sex and sexual behavior have become a preoccupation for the child, and whether the child responds to normal correction from adults or whether the behavior continues after normal corrective efforts.¹¹⁹ In determining whether the behavior involves potential for harm, it is important to consider the age/developmental differences of the children involved; any use of force, intimidation, or coercion; the presence of any emotional distress in the children involved; whether the behavior appears to be interfering with the children’s social development; and whether the behavior causes physical injury.^9,144,145

Parent education may include information about typical sexual development and how to distinguish SBPs from sex play; specific instructions for reducing exposure to sexually stimulating media or situations in the home; instructions for monitoring interactions with other children; suggestions for how parents should respond to sexualized behaviors; and teaching children rules about privacy, sexual behavior, and boundaries.^119,146

Parents and caregivers often are understandably concerned about the causes of the SBP. In some cases, there appears to be relatively clear sequence of events that explain the development of the SBP (such as young child’s being sexually abused by an uncle, followed by the child’s repeating the behavior with another child at daycare). However, such direct pathways are often not present, inasmuch as causes for human behavior can involve the interplay of multiple factors, and may not be fully knowable.⁸ Parents can be reassured that children with SBPs can be treated successfully without clear evidence of the origins of the behavior, with the exception of situations of ongoing sexual abuse.

Ongoing sexual abuse is of serious concern, both for the child’s welfare and for the success of intervention efforts. Indeed, subsequent sexual abuse appears to increase the likelihood of future SBPs.¹⁰⁵ In cases in which the Child Protective Services investigation of sexual abuse yields inconclusive results, interventions focused on educating children about sexual abuse, identifying whom children may tell if they were being abused, having significant adults support this message, and building support systems around the child have been recommended.⁷³ Repeated questioning and interviewing the child after thorough investigations are not recommended, because they may lead to inaccurate information and have potential deleterious effects on the child.¹¹⁹