Eden is 3. She is brought in by her grandmother, who is looking after her for the weekend whilst her parents have a weekend away. Embarrassed in a hushed voice, her grandmother tells you: “There’s something wrong; she keeps touching herself down there. She says it feels nice; she says it’s how she goes to sleep, one hand in her knickers and a thumb in her mouth.”
As clinicians working with children and young people, often our early career discussions of sex and children are isolated only to the abnormal, to the early detection of child sexual abuse, and to be vigilant for any abnormal sexualised behaviours. The trouble is that we have often not considered what is normal sexual behaviour of people younger than teenagers or adults.
Parents and carers are often similarly lacking in this knowledge, and generationally, we are more open to talking about sex, gender, masturbation and other topics which might have been considered an absolute taboo even 30 years ago.
It is also very much worth thinking about cultural and religious norms. As an atheist white British GP mother of two girls, we discuss things openly in our house, which I know some of my international and or more religious friends and colleagues find uncomfortable.
A key point when considering the human development of sexuality is that we are all potential sexual beings from birth. This does not mean that sexualised behaviour is normal or desirable in young children, but recognising that the genital region is a part of the body filled with nerve endings and pleasure receptors is a key place to start. Baby boys have erections seen in utero during pregnancy ultrasound scans, and these continue after birth as a largely involuntary function. Ejaculation does not occur until puberty. Curiosity about bodies, feelings and touch are a key part of childhood development. This is where the difficulty of differentiating “normal” vs. “worrying” behaviours starts to occur.
It is normal and healthy for some young children (boys and girls) to explore their bodies (including their genitals) for pleasure. Toddlers are naturally VERY curious, and this includes genitals. This degree of tactile exploration often coincides with potty training as the freedom of pants compared with nappies allows more access to an exciting and hitherto hidden region of the body.
It is never too early to teach children skills and information to help prevent sexual abuse or exploitation. There is evidence that open dialogue between children and their carers is protective. Parents should be encouraged to teach children unambiguous and correct names for their body parts and explain clearly that they belong to the child and should not be touched or seen by others (Kenny and Wurtele). Pacey, the UK Professional Association for Child carers and Early Years Education professionals, strongly encourages all childcare professionals to use age-appropriate correct anatomical names for all body parts. The NSPCC Pants Rules and Pantasaurous video are a brilliant resource to signpost families to if they are struggling with how to start these conversations.
Normal infant/preschool behaviour may include….
- Enjoying being naked
- Holding or playing with own genitals
- Attempting to touch or curiosity about other children’s genitals
- Interest in body parts and what they do
- Attempting to touch or curiosity about breasts, bottoms or genitals of adults
- Curiosity about the differences between boys and girls
Infant/preschool behaviour that is concerning often contains themes of persistence, secrecy, and power difference:
- Persistently touching the genitals of others
- Simulation of sexual activity in play
- Sexual behaviour between young children involving penetration with objects
- Forcing other children to engage in sexual play
- Preoccupation with adult sexual behaviour
- Pulling other children’s pants down/skirts up/trousers down against their will
- Talking about sex using adult slang
- Talking about sexual activities seen on TV/online
A quick word now about Infant Gratification “Seizures”. These are not true seizures but are commonly misdiagnosed as epilepsy or dystonia. Infantile and pre-adolescent masturbatory behaviour is common and a normal variant, even in younger babies who may kick their legs in car seats or bouncers rubbing their genitals against a tight strap. This may present as dystonic posturing, grunting, rocking, glassy-eyed, fixed staring. Older children may touch or rub themselves with toys or furniture. This occurs in girls as much as boys. It is not unusual for the cultural understanding of pleasure-seeking behaviour to normalise this in boys and pathologise this in girls; therefore, we, as clinicians, are more likely to see presentations in girls.
If there is any concern about seizure activity, referral and investigation are, of course, warranted. It may be appropriate to exclude genital infections (e.g. threadworms). It may be appropriate to facilitate a discussion with the child about the social acceptability of pleasure-seeking/comfort behaviours and why it may be better to avoid this in public. This may include distraction strategies.
By Primary School age, children are likely to show increasing curiosity about their bodies and perhaps how babies are made. Often this is explored through ‘rude jokes’, e.g. willy or poo rhymes, name calling etc. It is vital to take care to distinguish innocent curiosity and role play from the mimicking behaviour of children exposed to adult sexual behaviour. This may not be easy. Primary-age children should have increasing awareness of the difference between what should be public and what should be kept private, and hence, primary school-aged children who enjoy touching their genitals are likely to do this in private.
Masturbation is not uncommon in children of any gender. They may do this out of curiosity because it feels good to relax or to provide comfort when they are upset, tired or bored. Negative parental responses to this may lead a child to have feelings of shame and guilt around their own body, which can continue into adulthood.
It is important to consider a child or young person with learning or physical disabilities, remembering they may be more vulnerable to abuse but will still have the same sexual feelings as other children. However, they may arrive at a different rate of development.
Normal behaviour in primary school-aged children includes
- Feeling and touching their own genitals
- Expressing curiosity about other children’s genitals
- Curiosity about sex and relationships, e.g. differences between boys and girls, how sex happens, where babies come from, same-sex relationships
- An increasing sense of privacy about bodies
- Telling stories or asking questions using swear and slang words for parts of the body
Concerning behaviour in a school-age child would include:
- Frequent masturbation in front of others
- Sexual behaviour engaging significantly younger or less able children
- Forcing other children to take part in sexual activities
- Simulation of oral or penetrative sex
- Sourcing pornography online
- Questions about sexual activity which persist or are repeated frequently despite an answer having been given
- Mutual masturbation
- Persistent sexual images and ideas in talk, play and art
- Use of adult slang language to discuss sex
Toward Prevention of Childhood Sexual Abuse: Preschoolers’ Knowledge of Genital Body Parts Maureen C. Kenny, Florida International University, USA Sandy K. Wurtele, University of Colorado, Colorado Springs, USA: