Symposium on Behavioral Pediatrics
Common Sexual Problems of Children and Adolescents Sharon Satterfield, M.D. *
Sexual problems in children and adolescents are somewhat unique in that they must be viewed not only in light of the developmental continuum of the child, but in reference to whether the sexual behavior is indeed viewed as a "problem" by the child, the parents or the physician. There presently exists a great deal of confusion over the definition of "sexual problem," since this is largely culturally determined, and there is evidence that societal attitudes have changed in the past generation. 1 This article describes specific concerns likely to be identified by parents and the developmental conflicts responsible for certain symptoms, which mayor may not be viewed as normal.
THE PRESCHOOL CHILD Sexuality is a normal part of childhood from birth. Infants are physiologically capable of penile erection or vaginal lubrication, and infants and toddlers are frequently observed to masturbate to a state which appears similar to the adult orgasm. Sigmund Freud called attention to the importance of the oral zone of the infant and the concentration of pleasure associated with sucking. It is the mouth, then other areas of somatic contact, that first bring the infant awareness of a world around him. Infancy is a most concentrated time for touching in nutritive ways. Indeed, as Rene Spitz has demonstrated, touching is essential for normal emotional development, if not survival. 10 Oral gratification remains important as a sensual experience throughout life, through smoking, eating, or the oral types of sex foreplay. However, in our society the caressing kinds of touching tend to diminish after the age of 3. For this reason, the reappearance of "petting" in adolescence serves as an important learning step toward achieving a fulfilling sexual life as an adult. "Instructor in Psychiatry, University of Maryland Medical School; Fellow, Child Psychiatry, University of Maryland Hospital, Baltimore, Maryland
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As the infant begins to explore the world around him, he will begin with his own body. The discovery of certain areas that are pleasurable can be a fascinating experience, and punitive disruption of this normal autoerotic exploration can lead to anxiety, frustration and inhibition of the basic curiosity that leads to emotional and cognitive growth. From ages 1 to 3 years, the child encounters a great deal of attention focused on the genital area, primarily for controlling the processes of elimination. This can be particularly confusing, since, from the adult world, the connotation of "dirty" becomes superimposed on the toddler's perception of pleasure.
Masturbation and Nudity as Sexual Problems The earliest problems regarding sex brought to the pediatrician usually concern masturbation and nudity. This is most likely to represent parental concern rather than abnormal behavior on the part of the child, for example, the mother who becomes embarrassed when her 2 year old runs out on the porch nude or when her 3 year old masturbates in the bathtub. First, the behavior must be understood in light of the child's development. If the 2 year old is engaged in a struggle for autonomy with mother and learns that this type of behavior upsets her, he may test her by repeating it. It is also important to realize that the child reacts to instinctual drives, responding to what is pleasurable to him. He is confonted by a society which does not necessarily reward pleasure and is so sexually repressive as to neglect to teach the child to modify his behavior to fit its norms. He is left to learn about sexuality in confusing ways, by innuendo, a nasty look, a slap on the hand, or by parents ignoring certain questions. Often, these problems can be dealt with by the physician in an educational way. For instance, parents may be reassured that masturbation is a normal part of growing up and they should concentrate upon teaching their child where and when are the inappropriate times for masturbation to occur rather than trying to stop it. This can be an important opportunity for the child to learn the meaning of privacy. Parents may not accept assurance that masturbation is normal. It is important that their attitudes toward sexuality be explored if the child's behavior is to be understood. Since adult sexual functioning is determined, to a significant extent, by parental influences in the first few years of life, the willingness of the pediatrician to counsel parents in such matters must be regarded as essential. Excessive masturbation or inappropriate nudity _may represent a conflict among members of a family, as with the defiant child who persists in the behavior because it provokes or upsets the mother. The behavior may also symbolize unspoken family conflicts which result in a high level of anxiety for the child. It may be a sign of severe emotional disturbance within the child, as in the anxious neurotic or psychotic child. The psychotic or organically impaired child may masturbate excessively on the basis of a severe lack or excess of external stimulation. It is useful for the pediatrician to be able to determine the etiology of the behavior if a referral must be made, as to a psychiatrist, psycholo-
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gist, social agency or neurologist. Unless the behavior is in response to a recent traumatic event, it is unlikely that the child will simply "outgrow it. " An example of an acutely anxious child was a 3 year old boy brought by his parents to a pediatric clinic because of frequent masturbation, nightmares and refusal to obey his mother. His symptoms coincided with a change in his father's job 3 months earlier, so that the father was compelled to be away from home a great deal. His mother became progressively more protective of him and inadequate in disciplining him, as she used him more and more to alleviate her own anxiety and depression. His symptoms resulted from anxiety, both from the change in father's presence, but more particularly, the effect it had on mother, and the way she treated.him. Counseling the mother relieved the child's symptoms as well as her depression.
The Sexually Curious Years At about 3 years of age, the child becomes aware of the anatomical difference between sexes. Typically, the child becomes erotically attached to the parent of the opposite sex and develops feelings of rivalry toward the parent of the same sex. Freud labeled this period the oedipal stage. This is a time when the child exhibits his own body and often observes other children's genitalia, usually in a furtive manner, because he senses that parents do not approve. This curiosity is not only a natural step toward establishing one's own body image but of reaffirming the child's perception of being a boy or a girl (gender identity). This is a time when parents often question the pediatrician about what to do when the child crawls into their bed, or whether the child should be exposed to nudity in the home. There is tremendous controversy among sex educators over whether parental nudity is harmful to the "sexually sensitive" child at this age. Most feel that parental nudity is harmful if it serves to further provoke erotic feelings toward the parent of the opposite sex, particularly if the parental relationship is not sound or if it is disrupted by separation. Nudity is often difficult for children to understand, since there are so many restrictions upon it in the outside world. Normally, this stage comes to an end at about 6 years, when the child realizes that mommy and daddy's marriage will not dissolve and when he usually turns his energies to more industrious pursuits toward making friends of the same sex and identifying, rather than competing with, the parent of the same sex. There is tremendous concern in our country about "overstimulating" children sexually, either through pornography or simply talking openly about sex. Actually, the naturally curious child will seek answers, whether parents provide them or not. An evasive answer to a question may stimulate his imagination far more than a simple direct answer. This process of information-seeking is particularly evident in the fantasy construction of preschool children about where babies come from. It is often wise for parents to explore the child's fantasies when questions are asked and to correct their misconceptions, rather than to launch into a detailed anatomical account that means little to the child. For parents and professionals it is most important, if possible, for questions to be answered immediately with ease and candor.
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Gender Identity By the time a child is 2 or 3 years old he knows he is a boy or a girl. Interestingly, genetic and biological influences are less important to this sense of identity than the expectations and attitudes of the parents.6 The child further strengthens his gender identity through sex role' play with other children and, later, with the parent of the same sex. If a child persists in identifying himself as a member of the opposite sex, he is unlikely to "outgrow it," and he and the family should be thoroughly evaluated. These problems, though usually occurring earlier, often do not become evident until a child starts school. Ronnie was born a biologically normal male. At 14 years of age, he requested a sex change operation and persistently dressed in female clothing. His physician originally thought this to be a case of transient adolescent identity confusion, until he discovered that from infancy, Ronnie's mother had dressed him in girl's clothing. He had always played with dolls, and had preferred his sister's friends to the company of boys. Because Ronnie's behavior had fulfilled his mother's ex" pectations, she did not perceive any problems in childhood as had others in the family. The home environment had, therefore, had the predOIninant influences in Ronnie's sexual identity.
THE LATENCY CHILD Latency is the period of childhood between the oedipal period and puberty. Once it was thought to be a sexually dormant stage. However, the child keeps awake his interest and curiosity in sex, particularly through the peer group. Jump rope rhymes are full of sexual references. There is a great competition in learning dirty words and discovering pornography. Although the sexes have little to do with each other, both boys and girls are busy learning their respective sex roles through games and play. As they approach adolescence, sex play continues, leading to such games as "spin the bottle." This is an age when problems in children become identified because they are exposed to the outside world at school. Again, parents need to be reassured about the normal pursuits of childhood, particularly when children are prone to bring home new dirty words each week. At this age, children continuously test their parents' attitudes against those of the parents of their peers. They continue to piece together the facts of life and frequently need a little guidance in this area, given with openness, but not overwhelming in details which they do not understand. A common problem with which the physician must deal is precocious puberty, and puberty in general, since it occurs slightly earlier with each generation. Unfortunately, emotional and biological maturity do not necessarily coincide. The 10 year old who looks 14 has many expectations placed upon him unwittingly by adults, peers and particularly members of the opposite sex. The 9 year old girl may be particularly bewildered by menstruation, since restrooms of elementary schools are rarely equipped for such an occurrence, and teachers and mothers may have overlooked the need for practical advice about such matters. Any
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child entering an early growth spurt is expected to be more mature in other ways, yet may be most prone to uncertainties regarding his changing body and feelings. Another problem of preadolescence that seems to vary from one community to another is that of precocious dating patterns. This usually occurs as group dates or dances. There mayor may not be emphasis upon pairing off, although it is not unusual to see an unwitting parent push a child into dating early either for social rewards or to bolster the parent's self esteem. It is not out of place for the physician to intervene if these circumstances become apparent, since the results may be tragic, namely an acceleration of the dating process leading to premature sexual behavior or marriage. Possibly the most difficult situation which the physician must manage is the latency age child who demonstrates persistent sexual preoccupation which is inconsistent with his peers. This may indicate sexual exploitation by adults, either as rape or incest. These children, surprisingly, can talk about their experiences with a sensitive, non-probing professional. An example was Angela, who, at 10 years, was approaching men in her school offering to have intercourse with them. Angela readily told of submitting at age 9 to sexual advances by a teenage/ foster brother and his friend. She had taken these advances to be a sign of affection and she eagerly sought affection elsewhere. Other children preoccupied with sex may have been allowed to witness, or openly participate, in extramarital affairs of their parents. As with most forms of adult exploitation, the physician must counsel the parents and, in some instances, may need to involve a social agency. The children, deceptively, often repress traumatic experiences, and only later in adolescence or young adulthood do these past experiences interfere with successful heterosexual adjustment. The child should not be forced to talk about these experiences, though brief immediate counseling by an understanding adult may alleviate some of the traumatic aspects of the event. For situations which have existed a long time, the child may manifest more severe scars, hence more intensive intervention may be required.
ADOLESCENCE Erik Erikson describes early adolescence as a "physiological revolution," requiring the individual to integrate sexual impulses resulting from hormonal upsurgence, his natural productive capabilities, and the opportunities offered in social roles. The successful accomplishment of this developmental task leads to one's attaining a sense of identity and being able to relate to others on a truly intimate level, both physically and emotionally. Failure in the search for identity leads to isolation and distantiation. 2 Establishing one's identity involves mastering one's body image when the body is rapidly changing, consolidating one's sexual identity, developing self esteem, and gradually emerging independent from the
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family. Most specific sexual "problems" are symptoms of breakdown in the developmental tasks, personal problems left over from earlier stages, family or peer conflicts, or a difference in opinion between generations in defining "a problem." Early adolescence is characterized by concern about one's body and whether it is developing in a normal way. Apprehension over rapidly occurring changes may appear as moodiness, an insistent demand for privacy in the home, and as hypochondriacal somatic concerns. Often the teenager requires reassurance from the physician that he or she is indeed developing normally and on schedule. This is particularly important in view of the broad range of normality in the age of onset of pubescence. Girls, on the average, begin puberty 2 years ahead of boys. Thus, it is not surprising that they tend to date boys 1 to 2 years older and engage in their first petting experience a year or two before their male peers. l l Early adolescence is also characterized by a developmentally bisexual phase in which the individual may participate in group heterosexual experiences, but whose emotional ties are usually to friends of the same sex. Girls typically have female "crushes" on classmates or female teachers. With males, sex play is more likely to involve overt homosexual experiences, such as mutual masturbation. These episodes are usually exploratory and transitory in nature, not to be confused with adult homosexual behavior. Since most teenagers, because of identity confusion, fear at some point whether they are homosexual, there is the danger that an overt homosexual act, particularly with a confirmed homosexual, may cement this fantasy into reality. Some believe that adult homosexuality results from a "fixation" in this adolescent stage. Others note that many homosexuals appear to have functioned successfully on a heterosexual basis. Some believe that an aversion to the opposite sex on the basis of earlier experience leads to a homosexual orientation. A few think homosexual behavior to be hormonally determined. There is probably no single answer to this question and probably the most significant diagnostic criterion for the physician in determining whether homosexual behavior, if it is established, is normal, is the ability of the individual to develop meaningful relationships. It is important to remember, however, that, in the younger adolescent, sexual role choice is probably not established, and that teenagers may be seeking reassurance that their fantasies and behavior are normal. Under hormonal influence, sexual impulses are awakened in adolescence, resulting in dreams and fantasies which are quite frightening. Most teenagers fear at some point that their thoughts. are "crazy." Sexual myths which are commonly produced by the peer group add to this confusion. A common example of this phenomenon is the erroneous belief that masturbation causes mental illness. Some studies have shown large discrepancies between adolescents' sexual behavior and their awareness of biological processes.3 The physician, therefore, must be able to communicate with teens in a sensitive, non-threatening manner, being particularly aware of unspoken questions and avoiding the common error of assuming more knowledge than the teenager may possess.
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The peer group exerts a great deal of influence upon the adolescent. This should be acknowledged by any adult entering into a counseling relationship with a teenager. Values, knowledge and behavior at this time are influenced by peers. The extent of this influence rests upon past instillation of parental values and the adolescent's progress in establishing his own identity. In mid to late adolescence, heterosexual relationships generally develop, following a fairly predictable continuum of sex play: dating, kissing, deep kissing, breast stimulation over clothes, breast stimulation under clothes, genital apposition and sexual intercourse. 6 It must be emphasized that these are learning experiences, varying according to the individual. Masters and Johnson have noted the importance of adolescent sexual behavior, particularly citing traumatic experiences and conditioning in the etiology of various forms of adult sexual dysfunction. 5 Since it is the task of the adolescent to consolidate body image, sexual identity and self esteem, he faces a conflict in being capable of coitus but restrained socially. The social controls for sexual impulses might seem inconsistent with the search for sexual identity. The teenager is expected to carry a high level of sexual tension while continuing to explore and develop interpersonal relationships. The extent of sexual behavior in adolescence is quite controversial. Because of the age of the population, data are difficult to obtain and interpret. The Sorensen Report: Adolescent Sexuality in Contemporary America (1972) specifically studied the attitudes and behavior of young people from ages thirteen through nineteen years. Sexuality is clearly a personal resource for many adolescents. It is a lever that young people use in comparing themselves with parents and society... Young people view the realization of their own sexuality in terms of physical pleasure, the extent of their self confidence about sex and their relationships with others, their attractiveness, and the good and harm they are doing themselves. For some, having sex with another is the ideal means to introduce meaningful communication. They lack the ability to put their actions into words, and they do not always know how to extract opinions and ideas from other young people. Thirty-four per cent of all adolescents agree with the statement "having sex together is a good way for two people to become acquainted." 9
How frequent is sexual intercourse? Kinsey reported that one third of all single females had had intercourse by age 25 with less than 10 per cent by age 17. 4 Sorensen reports that 52 per cent of all adolescents have engaged in intercourse at age 19,45 per cent of single females. Zelnick and Kantner report 46.1 per cent of single females having had intercourse by age 19,12 Adolescents are a difficult population to sample. However, it is likely that sexual intercourse is more common at a younger age than when Kinsey's study was done. There is little doubt that sexual attitudes in America have changed significantly in the past generation.1. 7
Common Sexual Problems of Adolescence Inunderstanding adolescent sexual behavior, one should ascertain what the behavior means to the teenager and what developmental task is being pursued at that point. Sorensen reports that teenagers used sex in the following ways: for sake of physical pleasure, as means of com-
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munication, a search for new experience, as index of maturity, in service of the peer group conformity, as a challenge to parents, as a challenge to society, as reward and punishment, as an escape from loneliness and as an escape from other pressures. Problems of sexual identity and body image, parental separation struggles, conflict resulting from peer pressure and severe emotional disorders may contribute to behavior or fear which the physician is left to interpret. The sensitivity of the physician and the structure of the encounter will determine the type of information elicited from the adolescent. Whenever a teenager is having problems as a result of sexual activity, it is important to question both the conscious and subconscious reasons for the behavior. It is crucial that the teenager be assured of privacy and confidentiality. A routine history may include matter-of-fact questions appealing to the ubiquity of the situation, such as "Most teens masturbate. How do you feel about that?" or "What do you think about when you masturbate?" Most teenagers respond better to questions about their attitudes than their experience. Sexual identity problems may present in a variety of ways. A few examples are the following: 1. A 15 year old girl who diets excessively to keep from getting breasts, who wants to be a forest ranger, and who feels that men "get all the breaks." 2. A 15 year old boy, brought to a hospital clinic by his mother, who expresses fears of being impotent after attempting intercourse with one partner. 3. A 14 year old boy who started missing school "because all the guys think I'm a fag." This teenager, in fact, developed the persistent fear that he was homosexual. In this instance, the fear was an early symptom of a psychotic episode, although most teenagers worry at some point if they are homosexual. 4. The 18 year old girl who is concerned because she has not gotten pregnant yet. These problems often present a diagnostic dilemma. It is often useful to have an adolescent tell you how they think others perceive them, or to have them draw a picture of themselves. They may be invited to share any particular thoughts they have about their bodies. Asking their opinions about male and female roles, particularly as they compare their friends to their parents, can be quite useful. Peer groups are extremely important to teenagers, the choice of friends often being indicative of problems in the home or with self esteem. An example of this is a 13 year old girl from an orthodox religious family, who became involved in group sex and kept a diary of her activities. In a case which obviously involves rebellion against family values, it is usually advisable to interview as many family members as possible to ascertain where the conflict lies. Often the child's behavior may be a result of severe marital discord. Teenage pregnancy and venereal disease are problems which most physicians face at some point. Numerous family planning programs have demonstrated that those problems cannot be eliminated by educa-
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tion and medical attention alone. Here, again, it is crucial to examine what teenagers think of themselves, how they view their families and friends as influencing their behavior, and for what purpose they are using sexual intercourse. It is also important to remember that sexual activity occurring in adolescence need not be a symptom of pathology. The degree that it is normal for the particular individual can best be ascertained by presenting as a non-judgmental, objective, yet interested listener. The 17 year old girl may need to be reassured that early intercourse will not "stretch her out," rather than be greeted with raised eyebrows or scolded. The inability of a 16 year old girl to insert a tampon may be a serious precursor to vaginismus in later years and should be investigated. One must always keep in mind that experimental sexual behavior of adolescence evolves into the mature functioning adult. Sexual behavior should be examined in the context of the total development of the teenager. The physician must question whether growth is being promoted or retarded. It may be wise to pursue alternative outlets for sexual drives such as expression through athletic pursuits or dance. Efforts to simply repress sexual drives are rarely successful. The teenager may need to be assured that orgastic release through masturbation or noncoital sex play is not mentally or physically damaging and should not interfere with future sexual functioning. Chronic sexual arousal without orgasm, however, may result in future orgasmic dysfunction, particularly for the female. The resulting pelvic congestion may cause vaguely defined abdominal and back pains. "Hurry-up sex" which occurs in parked cars or under threat of parental discovery has been implicated by Masters and Johnson as an etiologic factor leading to premature ejaculation in the male. 5 Adolescent sexual behavior must also be examined in the context of the relationship. Does sexual behavior represent manipulation or coercion, or are the participants working toward intimacy? Are the partners ready on an individual basis to participate in the relationship and are they able to communicate their feelings to one another? What external factors affect the relationship? The physician faces a formidable challenge in counseling teenagers about their sexuality. Teenagers are often reluctant to discuss these matters with adults and are threatened by acknowledging that they might have a "problem." The physician, on the other hand, may be inhibited by his own biases, particularly if he has children the same age as the patient. He may over-identify with the patient or may assign a different value system to males and females. Furthermore, no common language exists when talking about sex. Adolescents are not particularly comfortable with medical terms. In spite of these problems, adolescents often need and accept counsel from a sensitive adult. Although any professional will inevitably have some biases, if these are acknowledged and examined by the individual, they need not interfere with therapeutic intervention with the patient. Some teenagers are able to work out their own conflicts in the presence of a patient, supportive listener.
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SUMMARY The pediatrician is often expected by families to deal with sexual problems of children and adolescents. The physician should be able to identify problems and to guide parents in more meaningful communication and education of their children. Hopefully, he will be able to identify family conflicts and make the appropriate intervention or referral. He should be aware of his own sexual attitudes so as to avoid having his bias interfere with treatment. The child's behavior should not be isolated, but considered in the context of his family, his peers, and his own growth and development. Often, it is more useful to advise the family than to work with a young child. Adolescents present particular problems because of their conflicts over sexual identity, their reluctance to admit to problems, and frequently a mistrust of adults. They often feel a need for a trusting relationship with an adult, however, and are able to relate to a sensitive, non-judgmental professional.
REFERENCES 1. Athanasiou, R.: A review of public attitudes on sexual issues. In Zubin, J., and Money, J., eds.: Contemporary Sexual Behavior, Critical Issues in the 1970's. Baltimore, The Johns Hopkins Press, 1973, pp. 361-390. 2. Erikson, E. H.: Childhood and Society. 2nd ed. New York, W. W. Norton, 1963, p. 263. 3. Gordon, S.: The Sexual Adolescent. N. Scituate, Mass. Duxbury Press. 4. Kinsey, A. C., Pomeroy, W. B., Martin, C. E., and Gebhard, P. H.: Sexual Behavior in the Human Female. Philadelphia, W. B. Saunders Company, 1953. 5. Masters, W. H., and Johnson, V. E.: Human Sexual Inadequacy. Boston, Little, Brown, & Co., 1970. 6. Money, J.: Reassignment related to hermaphroditism and transsexualism. In Green, R, and Money. J .. eds.: Transsexualism and Sex Reassignment. Baltimore. The Johns Hopkins Press, 1969, pp. 91-113. 7. Reiss, I.: Premarital sexual standards. In Broderick, C. B., and Bernard, J., eds: The Individual, Sex and Society. Baltimore, The Johns Hopkins Press, 1969, pp. 109-118. 8. Schofield, M. G.: The Sexual Behavior of Young People. Boston, Little, Brown, & Co., 1965, p. 29. 9. Sorensen, R C.: Adolescent Sexuality in Contemporary America. New York, World Publishing Co., 1973. . 10. Spitz, R A.: The First Year of Life. New York, International Universities Press, 1965, pp. 267-277. 11. Spitz, R. H., and Schumacher, S. S.: Developmental sexuality. Current Problems in Pediatrics, 1 :3, 1971. 12. Zelnick, M. and Kantner, J.: The probability of premarital intercourse. Social Science Research, 1 :335, 1972. 645 W. Redwood Street Baltimore, Maryland 21201
Common Sexual Problems of Children and Adolescents Sharon Satterfield, M.D. *
Sexual problems in children and adolescents are somewhat unique in that they must be viewed not only in light of the developmental continuum of the child, but in reference to whether the sexual behavior is indeed viewed as a "problem" by the child, the parents or the physician. There presently exists a great deal of confusion over the definition of "sexual problem," since this is largely culturally determined, and there is evidence that societal attitudes have changed in the past generation. 1 This article describes specific concerns likely to be identified by parents and the developmental conflicts responsible for certain symptoms, which mayor may not be viewed as normal.
THE PRESCHOOL CHILD Sexuality is a normal part of childhood from birth. Infants are physiologically capable of penile erection or vaginal lubrication, and infants and toddlers are frequently observed to masturbate to a state which appears similar to the adult orgasm. Sigmund Freud called attention to the importance of the oral zone of the infant and the concentration of pleasure associated with sucking. It is the mouth, then other areas of somatic contact, that first bring the infant awareness of a world around him. Infancy is a most concentrated time for touching in nutritive ways. Indeed, as Rene Spitz has demonstrated, touching is essential for normal emotional development, if not survival. 10 Oral gratification remains important as a sensual experience throughout life, through smoking, eating, or the oral types of sex foreplay. However, in our society the caressing kinds of touching tend to diminish after the age of 3. For this reason, the reappearance of "petting" in adolescence serves as an important learning step toward achieving a fulfilling sexual life as an adult. "Instructor in Psychiatry, University of Maryland Medical School; Fellow, Child Psychiatry, University of Maryland Hospital, Baltimore, Maryland
Pediat.ric Clinics of North America- Vol. 22, No.3, August 1975
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As the infant begins to explore the world around him, he will begin with his own body. The discovery of certain areas that are pleasurable can be a fascinating experience, and punitive disruption of this normal autoerotic exploration can lead to anxiety, frustration and inhibition of the basic curiosity that leads to emotional and cognitive growth. From ages 1 to 3 years, the child encounters a great deal of attention focused on the genital area, primarily for controlling the processes of elimination. This can be particularly confusing, since, from the adult world, the connotation of "dirty" becomes superimposed on the toddler's perception of pleasure.
Masturbation and Nudity as Sexual Problems The earliest problems regarding sex brought to the pediatrician usually concern masturbation and nudity. This is most likely to represent parental concern rather than abnormal behavior on the part of the child, for example, the mother who becomes embarrassed when her 2 year old runs out on the porch nude or when her 3 year old masturbates in the bathtub. First, the behavior must be understood in light of the child's development. If the 2 year old is engaged in a struggle for autonomy with mother and learns that this type of behavior upsets her, he may test her by repeating it. It is also important to realize that the child reacts to instinctual drives, responding to what is pleasurable to him. He is confonted by a society which does not necessarily reward pleasure and is so sexually repressive as to neglect to teach the child to modify his behavior to fit its norms. He is left to learn about sexuality in confusing ways, by innuendo, a nasty look, a slap on the hand, or by parents ignoring certain questions. Often, these problems can be dealt with by the physician in an educational way. For instance, parents may be reassured that masturbation is a normal part of growing up and they should concentrate upon teaching their child where and when are the inappropriate times for masturbation to occur rather than trying to stop it. This can be an important opportunity for the child to learn the meaning of privacy. Parents may not accept assurance that masturbation is normal. It is important that their attitudes toward sexuality be explored if the child's behavior is to be understood. Since adult sexual functioning is determined, to a significant extent, by parental influences in the first few years of life, the willingness of the pediatrician to counsel parents in such matters must be regarded as essential. Excessive masturbation or inappropriate nudity _may represent a conflict among members of a family, as with the defiant child who persists in the behavior because it provokes or upsets the mother. The behavior may also symbolize unspoken family conflicts which result in a high level of anxiety for the child. It may be a sign of severe emotional disturbance within the child, as in the anxious neurotic or psychotic child. The psychotic or organically impaired child may masturbate excessively on the basis of a severe lack or excess of external stimulation. It is useful for the pediatrician to be able to determine the etiology of the behavior if a referral must be made, as to a psychiatrist, psycholo-
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gist, social agency or neurologist. Unless the behavior is in response to a recent traumatic event, it is unlikely that the child will simply "outgrow it. " An example of an acutely anxious child was a 3 year old boy brought by his parents to a pediatric clinic because of frequent masturbation, nightmares and refusal to obey his mother. His symptoms coincided with a change in his father's job 3 months earlier, so that the father was compelled to be away from home a great deal. His mother became progressively more protective of him and inadequate in disciplining him, as she used him more and more to alleviate her own anxiety and depression. His symptoms resulted from anxiety, both from the change in father's presence, but more particularly, the effect it had on mother, and the way she treated.him. Counseling the mother relieved the child's symptoms as well as her depression.
The Sexually Curious Years At about 3 years of age, the child becomes aware of the anatomical difference between sexes. Typically, the child becomes erotically attached to the parent of the opposite sex and develops feelings of rivalry toward the parent of the same sex. Freud labeled this period the oedipal stage. This is a time when the child exhibits his own body and often observes other children's genitalia, usually in a furtive manner, because he senses that parents do not approve. This curiosity is not only a natural step toward establishing one's own body image but of reaffirming the child's perception of being a boy or a girl (gender identity). This is a time when parents often question the pediatrician about what to do when the child crawls into their bed, or whether the child should be exposed to nudity in the home. There is tremendous controversy among sex educators over whether parental nudity is harmful to the "sexually sensitive" child at this age. Most feel that parental nudity is harmful if it serves to further provoke erotic feelings toward the parent of the opposite sex, particularly if the parental relationship is not sound or if it is disrupted by separation. Nudity is often difficult for children to understand, since there are so many restrictions upon it in the outside world. Normally, this stage comes to an end at about 6 years, when the child realizes that mommy and daddy's marriage will not dissolve and when he usually turns his energies to more industrious pursuits toward making friends of the same sex and identifying, rather than competing with, the parent of the same sex. There is tremendous concern in our country about "overstimulating" children sexually, either through pornography or simply talking openly about sex. Actually, the naturally curious child will seek answers, whether parents provide them or not. An evasive answer to a question may stimulate his imagination far more than a simple direct answer. This process of information-seeking is particularly evident in the fantasy construction of preschool children about where babies come from. It is often wise for parents to explore the child's fantasies when questions are asked and to correct their misconceptions, rather than to launch into a detailed anatomical account that means little to the child. For parents and professionals it is most important, if possible, for questions to be answered immediately with ease and candor.
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Gender Identity By the time a child is 2 or 3 years old he knows he is a boy or a girl. Interestingly, genetic and biological influences are less important to this sense of identity than the expectations and attitudes of the parents.6 The child further strengthens his gender identity through sex role' play with other children and, later, with the parent of the same sex. If a child persists in identifying himself as a member of the opposite sex, he is unlikely to "outgrow it," and he and the family should be thoroughly evaluated. These problems, though usually occurring earlier, often do not become evident until a child starts school. Ronnie was born a biologically normal male. At 14 years of age, he requested a sex change operation and persistently dressed in female clothing. His physician originally thought this to be a case of transient adolescent identity confusion, until he discovered that from infancy, Ronnie's mother had dressed him in girl's clothing. He had always played with dolls, and had preferred his sister's friends to the company of boys. Because Ronnie's behavior had fulfilled his mother's ex" pectations, she did not perceive any problems in childhood as had others in the family. The home environment had, therefore, had the predOIninant influences in Ronnie's sexual identity.
THE LATENCY CHILD Latency is the period of childhood between the oedipal period and puberty. Once it was thought to be a sexually dormant stage. However, the child keeps awake his interest and curiosity in sex, particularly through the peer group. Jump rope rhymes are full of sexual references. There is a great competition in learning dirty words and discovering pornography. Although the sexes have little to do with each other, both boys and girls are busy learning their respective sex roles through games and play. As they approach adolescence, sex play continues, leading to such games as "spin the bottle." This is an age when problems in children become identified because they are exposed to the outside world at school. Again, parents need to be reassured about the normal pursuits of childhood, particularly when children are prone to bring home new dirty words each week. At this age, children continuously test their parents' attitudes against those of the parents of their peers. They continue to piece together the facts of life and frequently need a little guidance in this area, given with openness, but not overwhelming in details which they do not understand. A common problem with which the physician must deal is precocious puberty, and puberty in general, since it occurs slightly earlier with each generation. Unfortunately, emotional and biological maturity do not necessarily coincide. The 10 year old who looks 14 has many expectations placed upon him unwittingly by adults, peers and particularly members of the opposite sex. The 9 year old girl may be particularly bewildered by menstruation, since restrooms of elementary schools are rarely equipped for such an occurrence, and teachers and mothers may have overlooked the need for practical advice about such matters. Any
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child entering an early growth spurt is expected to be more mature in other ways, yet may be most prone to uncertainties regarding his changing body and feelings. Another problem of preadolescence that seems to vary from one community to another is that of precocious dating patterns. This usually occurs as group dates or dances. There mayor may not be emphasis upon pairing off, although it is not unusual to see an unwitting parent push a child into dating early either for social rewards or to bolster the parent's self esteem. It is not out of place for the physician to intervene if these circumstances become apparent, since the results may be tragic, namely an acceleration of the dating process leading to premature sexual behavior or marriage. Possibly the most difficult situation which the physician must manage is the latency age child who demonstrates persistent sexual preoccupation which is inconsistent with his peers. This may indicate sexual exploitation by adults, either as rape or incest. These children, surprisingly, can talk about their experiences with a sensitive, non-probing professional. An example was Angela, who, at 10 years, was approaching men in her school offering to have intercourse with them. Angela readily told of submitting at age 9 to sexual advances by a teenage/ foster brother and his friend. She had taken these advances to be a sign of affection and she eagerly sought affection elsewhere. Other children preoccupied with sex may have been allowed to witness, or openly participate, in extramarital affairs of their parents. As with most forms of adult exploitation, the physician must counsel the parents and, in some instances, may need to involve a social agency. The children, deceptively, often repress traumatic experiences, and only later in adolescence or young adulthood do these past experiences interfere with successful heterosexual adjustment. The child should not be forced to talk about these experiences, though brief immediate counseling by an understanding adult may alleviate some of the traumatic aspects of the event. For situations which have existed a long time, the child may manifest more severe scars, hence more intensive intervention may be required.
ADOLESCENCE Erik Erikson describes early adolescence as a "physiological revolution," requiring the individual to integrate sexual impulses resulting from hormonal upsurgence, his natural productive capabilities, and the opportunities offered in social roles. The successful accomplishment of this developmental task leads to one's attaining a sense of identity and being able to relate to others on a truly intimate level, both physically and emotionally. Failure in the search for identity leads to isolation and distantiation. 2 Establishing one's identity involves mastering one's body image when the body is rapidly changing, consolidating one's sexual identity, developing self esteem, and gradually emerging independent from the
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family. Most specific sexual "problems" are symptoms of breakdown in the developmental tasks, personal problems left over from earlier stages, family or peer conflicts, or a difference in opinion between generations in defining "a problem." Early adolescence is characterized by concern about one's body and whether it is developing in a normal way. Apprehension over rapidly occurring changes may appear as moodiness, an insistent demand for privacy in the home, and as hypochondriacal somatic concerns. Often the teenager requires reassurance from the physician that he or she is indeed developing normally and on schedule. This is particularly important in view of the broad range of normality in the age of onset of pubescence. Girls, on the average, begin puberty 2 years ahead of boys. Thus, it is not surprising that they tend to date boys 1 to 2 years older and engage in their first petting experience a year or two before their male peers. l l Early adolescence is also characterized by a developmentally bisexual phase in which the individual may participate in group heterosexual experiences, but whose emotional ties are usually to friends of the same sex. Girls typically have female "crushes" on classmates or female teachers. With males, sex play is more likely to involve overt homosexual experiences, such as mutual masturbation. These episodes are usually exploratory and transitory in nature, not to be confused with adult homosexual behavior. Since most teenagers, because of identity confusion, fear at some point whether they are homosexual, there is the danger that an overt homosexual act, particularly with a confirmed homosexual, may cement this fantasy into reality. Some believe that adult homosexuality results from a "fixation" in this adolescent stage. Others note that many homosexuals appear to have functioned successfully on a heterosexual basis. Some believe that an aversion to the opposite sex on the basis of earlier experience leads to a homosexual orientation. A few think homosexual behavior to be hormonally determined. There is probably no single answer to this question and probably the most significant diagnostic criterion for the physician in determining whether homosexual behavior, if it is established, is normal, is the ability of the individual to develop meaningful relationships. It is important to remember, however, that, in the younger adolescent, sexual role choice is probably not established, and that teenagers may be seeking reassurance that their fantasies and behavior are normal. Under hormonal influence, sexual impulses are awakened in adolescence, resulting in dreams and fantasies which are quite frightening. Most teenagers fear at some point that their thoughts. are "crazy." Sexual myths which are commonly produced by the peer group add to this confusion. A common example of this phenomenon is the erroneous belief that masturbation causes mental illness. Some studies have shown large discrepancies between adolescents' sexual behavior and their awareness of biological processes.3 The physician, therefore, must be able to communicate with teens in a sensitive, non-threatening manner, being particularly aware of unspoken questions and avoiding the common error of assuming more knowledge than the teenager may possess.
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The peer group exerts a great deal of influence upon the adolescent. This should be acknowledged by any adult entering into a counseling relationship with a teenager. Values, knowledge and behavior at this time are influenced by peers. The extent of this influence rests upon past instillation of parental values and the adolescent's progress in establishing his own identity. In mid to late adolescence, heterosexual relationships generally develop, following a fairly predictable continuum of sex play: dating, kissing, deep kissing, breast stimulation over clothes, breast stimulation under clothes, genital apposition and sexual intercourse. 6 It must be emphasized that these are learning experiences, varying according to the individual. Masters and Johnson have noted the importance of adolescent sexual behavior, particularly citing traumatic experiences and conditioning in the etiology of various forms of adult sexual dysfunction. 5 Since it is the task of the adolescent to consolidate body image, sexual identity and self esteem, he faces a conflict in being capable of coitus but restrained socially. The social controls for sexual impulses might seem inconsistent with the search for sexual identity. The teenager is expected to carry a high level of sexual tension while continuing to explore and develop interpersonal relationships. The extent of sexual behavior in adolescence is quite controversial. Because of the age of the population, data are difficult to obtain and interpret. The Sorensen Report: Adolescent Sexuality in Contemporary America (1972) specifically studied the attitudes and behavior of young people from ages thirteen through nineteen years. Sexuality is clearly a personal resource for many adolescents. It is a lever that young people use in comparing themselves with parents and society... Young people view the realization of their own sexuality in terms of physical pleasure, the extent of their self confidence about sex and their relationships with others, their attractiveness, and the good and harm they are doing themselves. For some, having sex with another is the ideal means to introduce meaningful communication. They lack the ability to put their actions into words, and they do not always know how to extract opinions and ideas from other young people. Thirty-four per cent of all adolescents agree with the statement "having sex together is a good way for two people to become acquainted." 9
How frequent is sexual intercourse? Kinsey reported that one third of all single females had had intercourse by age 25 with less than 10 per cent by age 17. 4 Sorensen reports that 52 per cent of all adolescents have engaged in intercourse at age 19,45 per cent of single females. Zelnick and Kantner report 46.1 per cent of single females having had intercourse by age 19,12 Adolescents are a difficult population to sample. However, it is likely that sexual intercourse is more common at a younger age than when Kinsey's study was done. There is little doubt that sexual attitudes in America have changed significantly in the past generation.1. 7
Common Sexual Problems of Adolescence Inunderstanding adolescent sexual behavior, one should ascertain what the behavior means to the teenager and what developmental task is being pursued at that point. Sorensen reports that teenagers used sex in the following ways: for sake of physical pleasure, as means of com-
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munication, a search for new experience, as index of maturity, in service of the peer group conformity, as a challenge to parents, as a challenge to society, as reward and punishment, as an escape from loneliness and as an escape from other pressures. Problems of sexual identity and body image, parental separation struggles, conflict resulting from peer pressure and severe emotional disorders may contribute to behavior or fear which the physician is left to interpret. The sensitivity of the physician and the structure of the encounter will determine the type of information elicited from the adolescent. Whenever a teenager is having problems as a result of sexual activity, it is important to question both the conscious and subconscious reasons for the behavior. It is crucial that the teenager be assured of privacy and confidentiality. A routine history may include matter-of-fact questions appealing to the ubiquity of the situation, such as "Most teens masturbate. How do you feel about that?" or "What do you think about when you masturbate?" Most teenagers respond better to questions about their attitudes than their experience. Sexual identity problems may present in a variety of ways. A few examples are the following: 1. A 15 year old girl who diets excessively to keep from getting breasts, who wants to be a forest ranger, and who feels that men "get all the breaks." 2. A 15 year old boy, brought to a hospital clinic by his mother, who expresses fears of being impotent after attempting intercourse with one partner. 3. A 14 year old boy who started missing school "because all the guys think I'm a fag." This teenager, in fact, developed the persistent fear that he was homosexual. In this instance, the fear was an early symptom of a psychotic episode, although most teenagers worry at some point if they are homosexual. 4. The 18 year old girl who is concerned because she has not gotten pregnant yet. These problems often present a diagnostic dilemma. It is often useful to have an adolescent tell you how they think others perceive them, or to have them draw a picture of themselves. They may be invited to share any particular thoughts they have about their bodies. Asking their opinions about male and female roles, particularly as they compare their friends to their parents, can be quite useful. Peer groups are extremely important to teenagers, the choice of friends often being indicative of problems in the home or with self esteem. An example of this is a 13 year old girl from an orthodox religious family, who became involved in group sex and kept a diary of her activities. In a case which obviously involves rebellion against family values, it is usually advisable to interview as many family members as possible to ascertain where the conflict lies. Often the child's behavior may be a result of severe marital discord. Teenage pregnancy and venereal disease are problems which most physicians face at some point. Numerous family planning programs have demonstrated that those problems cannot be eliminated by educa-
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tion and medical attention alone. Here, again, it is crucial to examine what teenagers think of themselves, how they view their families and friends as influencing their behavior, and for what purpose they are using sexual intercourse. It is also important to remember that sexual activity occurring in adolescence need not be a symptom of pathology. The degree that it is normal for the particular individual can best be ascertained by presenting as a non-judgmental, objective, yet interested listener. The 17 year old girl may need to be reassured that early intercourse will not "stretch her out," rather than be greeted with raised eyebrows or scolded. The inability of a 16 year old girl to insert a tampon may be a serious precursor to vaginismus in later years and should be investigated. One must always keep in mind that experimental sexual behavior of adolescence evolves into the mature functioning adult. Sexual behavior should be examined in the context of the total development of the teenager. The physician must question whether growth is being promoted or retarded. It may be wise to pursue alternative outlets for sexual drives such as expression through athletic pursuits or dance. Efforts to simply repress sexual drives are rarely successful. The teenager may need to be assured that orgastic release through masturbation or noncoital sex play is not mentally or physically damaging and should not interfere with future sexual functioning. Chronic sexual arousal without orgasm, however, may result in future orgasmic dysfunction, particularly for the female. The resulting pelvic congestion may cause vaguely defined abdominal and back pains. "Hurry-up sex" which occurs in parked cars or under threat of parental discovery has been implicated by Masters and Johnson as an etiologic factor leading to premature ejaculation in the male. 5 Adolescent sexual behavior must also be examined in the context of the relationship. Does sexual behavior represent manipulation or coercion, or are the participants working toward intimacy? Are the partners ready on an individual basis to participate in the relationship and are they able to communicate their feelings to one another? What external factors affect the relationship? The physician faces a formidable challenge in counseling teenagers about their sexuality. Teenagers are often reluctant to discuss these matters with adults and are threatened by acknowledging that they might have a "problem." The physician, on the other hand, may be inhibited by his own biases, particularly if he has children the same age as the patient. He may over-identify with the patient or may assign a different value system to males and females. Furthermore, no common language exists when talking about sex. Adolescents are not particularly comfortable with medical terms. In spite of these problems, adolescents often need and accept counsel from a sensitive adult. Although any professional will inevitably have some biases, if these are acknowledged and examined by the individual, they need not interfere with therapeutic intervention with the patient. Some teenagers are able to work out their own conflicts in the presence of a patient, supportive listener.
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SUMMARY The pediatrician is often expected by families to deal with sexual problems of children and adolescents. The physician should be able to identify problems and to guide parents in more meaningful communication and education of their children. Hopefully, he will be able to identify family conflicts and make the appropriate intervention or referral. He should be aware of his own sexual attitudes so as to avoid having his bias interfere with treatment. The child's behavior should not be isolated, but considered in the context of his family, his peers, and his own growth and development. Often, it is more useful to advise the family than to work with a young child. Adolescents present particular problems because of their conflicts over sexual identity, their reluctance to admit to problems, and frequently a mistrust of adults. They often feel a need for a trusting relationship with an adult, however, and are able to relate to a sensitive, non-judgmental professional.
REFERENCES 1. Athanasiou, R.: A review of public attitudes on sexual issues. In Zubin, J., and Money, J., eds.: Contemporary Sexual Behavior, Critical Issues in the 1970's. Baltimore, The Johns Hopkins Press, 1973, pp. 361-390. 2. Erikson, E. H.: Childhood and Society. 2nd ed. New York, W. W. Norton, 1963, p. 263. 3. Gordon, S.: The Sexual Adolescent. N. Scituate, Mass. Duxbury Press. 4. Kinsey, A. C., Pomeroy, W. B., Martin, C. E., and Gebhard, P. H.: Sexual Behavior in the Human Female. Philadelphia, W. B. Saunders Company, 1953. 5. Masters, W. H., and Johnson, V. E.: Human Sexual Inadequacy. Boston, Little, Brown, & Co., 1970. 6. Money, J.: Reassignment related to hermaphroditism and transsexualism. In Green, R, and Money. J .. eds.: Transsexualism and Sex Reassignment. Baltimore. The Johns Hopkins Press, 1969, pp. 91-113. 7. Reiss, I.: Premarital sexual standards. In Broderick, C. B., and Bernard, J., eds: The Individual, Sex and Society. Baltimore, The Johns Hopkins Press, 1969, pp. 109-118. 8. Schofield, M. G.: The Sexual Behavior of Young People. Boston, Little, Brown, & Co., 1965, p. 29. 9. Sorensen, R C.: Adolescent Sexuality in Contemporary America. New York, World Publishing Co., 1973. . 10. Spitz, R A.: The First Year of Life. New York, International Universities Press, 1965, pp. 267-277. 11. Spitz, R. H., and Schumacher, S. S.: Developmental sexuality. Current Problems in Pediatrics, 1 :3, 1971. 12. Zelnick, M. and Kantner, J.: The probability of premarital intercourse. Social Science Research, 1 :335, 1972. 645 W. Redwood Street Baltimore, Maryland 21201
