Keywords
Sexuality, homosexuality, gender identity, gender dysphoria
The development of sexuality occurs throughout a child’s life. Sexuality includes the interplay of gender roles, gender identity, sexual orientation, and sexual behaviors, and it is influenced by biological and social factors, as well as individual experience. Pediatricians are likely to be consulted if parents have a concern about their child’s sexual development or behavior. A pediatrician who provides an open and nonjudgmental environment will also be a valuable resource for an adolescent with questions about sexual behaviors, homosexuality, and/or gender identity ( Table 23.1 ).
| Gender identity |
| Internal sense of one’s self as male, female, or other |
| Cisgender |
| An individual whose gender identity aligns with physical sex characteristics |
| Transgender |
| An individual whose gender identity and expression is not consistent with the sex assigned at birth |
| Gender role |
| Culturally derived associations for behaviors and appearance that signal being male or female |
| Gender expression |
| Behaviors and appearance used to communicate one’s gender identity |
Development of Sexuality
Sexual development begins early on in childhood. Often, parents express concern when their male infant has an erection, or when their child touches his/her genitals during diaper changes or bathing. During the preschool period, masturbation occurs in both sexes. Reassurance from the pediatrician is critical as these behaviors are part of typical child development, represent normal exploration of the body, and should not be treated punitively. However, it is important for children by age 3 years to learn the proper anatomical names for their body parts and that genitals and sexual behaviors are private. It is common for pre-elementary age children to touch their genitals in public. However, showing their genitals to others, “playing doctor,” or imitating intercourse or other adult sexual behaviors is unusual at this age. If this behavior is occurring, the child should be evaluated for exposure to inappropriate sexual material and possible sexual abuse (see Chapter 22 ).
Children in elementary school are typically intrigued by the topics of pregnancy, birth, and gender roles. They often will begin to preferentially play with children of the same gender. Their curiosity and inquiries should be met with accurate information and limited judgment so that future questions will be directed to reliable resources and not answered by peers and the media.
The biological, social, and cognitive changes that occur during adolescence place a focus on sexuality. Puberty can be both scary and exciting. One of the principal developmental tasks of this period is to become comfortable with one’s own sexuality. This is often achieved through questioning and experimentation. Some teenagers may try out different sexual practices, including those with members of the same sex, as they explore their own emerging sexuality. Almost half of high school students report ever having had sexual intercourse. The nature of these experiences does not necessarily predict sexual orientation, and similarly, stereotypical masculine and feminine traits do not predict sexual orientation either.
Sexual orientation, the pattern of physical and emotional arousal toward another person, is not always the same as sexual behavior. Typically, an individual’s sexual orientation emerges before or early in adolescence. Although many adolescents have sexual experiences with a same-sex partner (10-25%, and more often reported by males than females), fewer will affirm homosexual sexual orientation by late adolescence. By 18 years of age, the majority of individuals endorse certainty around their sexual orientation.
Homosexuality
There is no reliable way to predict an individual’s sexual orientation. Identical twins (even twins raised in separate families) show a higher concordance rate for sexual orientation than would be expected by chance alone, but nowhere near 100%, as would be expected if genetics were the sole determinant. Attempts to correlate brain imaging or levels of androgens and estrogens with sexual orientation have thus far been inconsistent at best. Although it is well established that parents tend to treat boys and girls differently, there is no evidence that parental behavior alters the developmental trajectory towards a particular sexual orientation.
It is currently estimated that about 10% of adults self-identify as homosexual, meaning they are attracted to people of the same gender. Homosexual children and adolescents face stigmatization derived from homophobia and heterosexism, ostracism, and family rejection. A persistent negative societal attitude toward homosexuality is reflected in the higher rates of social isolation, verbal harassment, and physical assault experienced by sexual minority youth. Additionally, educational and unbiased information about homosexuality is often not available in school and community settings, and homophobic jokes, teasing, and violence are common. Not surprisingly, sexual minority youth are at high risk for having a negative self-esteem, mental health issues, substance abuse, and sexual risk-taking behaviors. Sexual minority youth are more than twice as likely to report considering suicide than their heterosexual peers; rates of legal and illegal substance abuse are significantly higher.
There are also significant health disparities for sexual minority youth related to sexual health outcomes. Although sexual behaviors, not sexual orientation, determine risk of sexually transmitted infections (STI), sexual minority youth are more likely to have had intercourse at a younger age, less likely to use contraception, and report a greater number of sexual partners as compared to heterosexual peers. Rates of STI in the minority group of men who have sex with men (MSM) have not declined along with the downward trend of STI in adolescents overall, including rates of human immunodeficiency virus (HIV). Although education about safe sexual practices should be part of all adolescent well-child visits, Centers for Disease Control and Prevention (CDC) guidelines recommend asking about the gender of all sex partners as part of STI risk assessment. Health care providers should be aware of specific STI screening recommendations for MSM related to anal intercourse (see Chapter 116 ). Many adolescents who identify as women who have sex with women (WSW) have also had sex with men and will require cervical cancer screening per guidelines. Immunization for human papillomavirus per CDC guidelines is recommended for adolescents regardless of gender or sexual behavior. Additionally, discussions around highly effective birth control methods are prudent with both heterosexual and sexual minority youth.
Acknowledging that one is homosexual and disclosing it to one’s parents is often extremely stressful. Although many parents are supportive of their child’s sexual orientation, some parents, particularly those who view this behavior as immoral, may reject their child. Adolescents should be counseled that even parents whose initial reaction is one of shock, fear, or grief can come to accept their child’s homosexuality. Homosexual youth are at a high risk for homelessness as a consequence of parental rejection. Interventions designed to change sexual orientation are strongly opposed and are not only unsuccessful, but can be detrimental to the mental health of the child or adolescent. Health care providers should provide reassurance to parents feeling guilt or shame by affirming that sexual minority youth are normal and sexual orientation is not related to parenting practices. Evidence supports improved health outcomes for sexual minority youth who experience family connectedness and receive encouragement and positive support for their sexual orientation from their parents. For medical and psychosocial reasons, health care providers need to provide an environment in which adolescents feel comfortable discussing their sexual orientation and families can find the support and resources they need ( Table 23.2 ).
