Contemporary Definitions

Sexuality has been defined by the Sexuality Information and Education Council of the United States (SIECUS, 2010, p 1) as encompassing:

the sexual knowledge, beliefs, attitudes, values, and behaviors of individuals. Its various dimensions involve the anatomy, physiology, and biochemistry of the sexual response system; identity, orientation, roles, and personality; and thoughts, feelings, and relationships. Sexuality is influenced by ethical, spiritual, cultural, and moral concerns. All persons are sexual, in the broadest sense of the word.

Murphy and Elias (2006, p 398) summarize that:

sexuality extends beyond genital sex to include gender-role and socialization, physical maturation and body image, social relationships, and future social aspirations.

Both definitions illustrate the multidimensional process of sexual development. The complexity of sexuality hinges on the key notion of gender. The following contemporary definitions explore this notion more fully:

an individual’s attractions to the same or opposite sex. Sexual orientation is not dichotomous, and individuals tend to fall along a continuum of sexual expression and desires rather than into exclusive categories. The phrase sexual preference implies choice and should not be used in reference to sexual orientation.

For most people gender identity, role, and gender behaviors are congruent (heterosexual), and they are attracted to the opposite sex. For others, their gender manifestations do not match their gender orientation, and they are attracted to the same sex (homosexual). As discussed, many cultures accept more ambiguity between gender role, gender assignment, and symbolic behaviors, allowing permutations of the expression of sexuality.

Individuals’ sexual orientation is not necessarily the same as their sexual activity or their sexual feelings. Effects of defects in androgen biosynthesis on brain tissue may alter the perception of body image and influence sexual behavior (Ahmed et al, 2004). Adolescents may express different sexual behaviors, including short-term homosexual experiences. Teens may actually not be sexually active, but label themselves gay, lesbian, or bisexual because of to whom they are physically or emotionally attracted.

Sexual Health

A new working definition of sexual health has been put forth by a group of international experts (Glasier et al, 2006, p 3):

Sexual health is a state of physical, emotional, mental, and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction, or infirmity. Sexual health needs a positive and respectful approach to sexuality and sexual relationships, and the possibility of having pleasurable and safe sexual experiences that are free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all individuals must be respected, protected, and satisfied.

Sexual function incorporates the biological component of the human sexual response cycle and refers to the ability to give and receive sexual pleasure. Sexual self-concept is the psychological component of sexuality, the image one has of oneself as a man or a woman, and the evaluation of one’s adequacy in masculine and feminine roles. Sexual relationships refer to the social domain of sexuality and include the interpersonal relationships in which one’s sexuality is shared with others.

Infancy to 2 Years Old

Newborn infants are reflexive beings, responding to their physical environment without hesitation or cognition. Sexual reflexes are present prenatally and are easily stimulated in the infant. It is not uncommon to observe a penile erection in prenatal ultrasounds or in the nursing child, for example. Just as infants are fascinated by and explore their hands and feet, they explore their genitalia. Touching the genitalia—even masturbating—is pleasurable and soothing, is a natural part of exploring their environment, and begins as early as 3 to 5 months old. The provider should point out the spontaneity of this reflexive behavior so that a parent does not assign an adult sexuality interpretation to it.

Healthy parent-infant bonding requires physical contact and social interaction. Parents must hold, cuddle, stroke, talk to, look at, and respond to children if children are to develop a sense of trust, on which intimacy will be based in later years, and a positive self-image.

By the end of the first year, the child can differentiate between the sexes; some may even discriminate between sex-assigned toys. As society furthers its influence, children form their identities early and learn about their gender roles from the reinforcement of behaviors expected of males and females.

Two to 5 Years Old

Toddlers are able to recognize and pronounce themselves “I’m a girl” or “I’m a boy,” but they can easily confuse gender in others and sometimes in themselves. Changing one’s style of clothes, for example, can be perceived as a change in gender. Children cannot integrate gender identity into their self-concept until they understand that gender is a permanent condition. The age at which this notion occurs is around 4 or 5 years old. Theorists argue that gender identity is fully attained between 5 and 7 years old, at which time this identity truly motivates sex-appropriate gender behavior (Ahmed et al, 2004).

Children in this age group are extremely curious about their environment; they love to explore and experiment. Up to the age of 5 years, the variety and frequency of sexual behaviors increase, then start decreasing (Kellogg, 2009). Children have a cognitive awareness of the pleasure self-stimulation gives them and frequently masturbate, but, as with infants, they attribute no erotic or sexual meaning to their actions. They lack the concept of personal space and how their behavior may be misinterpreted as being sexual or improper. This is a good time for parents to discuss the notion of “private parts” and begin to teach the child that self-stimulation is acceptable, but done in private. Parental redirection is usually all that is required (Kellogg, 2009).

The combination of curiosity and lack of self-consciousness characteristic of toddlers can contribute to embarrassing social incidents for their parents. They may be curious about what others look like under their clothes, they may touch other children’s bodies, “play doctor,” pretend to be Mommy and Daddy, and may enjoy running around naked. By 4 years old children may attach themselves more to the parent of the opposite sex.

Parents should be encouraged to use the appropriate names for body parts and bodily functions, even though they may also be using slang words. This will enable children to better comprehend discussions with health providers, teachers, or health educators when the anatomical and physiological terms are used.

Because children at this age interpret statements literally and have “magical” thinking, their understandings of the physical self can be distorted, and lengthy explanations about body functions can be misunderstood. Parents should help children understand that they and their bodies come in different shapes, sizes, and colors; that all of these are equally important; that boys and girls also share the same parts, but different genital parts; and that sharing and respect are important aspects for developing friendships. It is appropriate for parents to introduce the notion of germs and hygiene, such as washing hands. This will help establish a framework for parents to advance the discussion to include sexually transmitted infections later in life.

Friedrich and colleagues (1998) noted that children who spend more time in childcare environments demonstrate a larger number and frequency of observed sexual behaviors. Other situational factors can induce an increase in observed sexual behaviors in this age group, such as the birth of a new sibling, watching their mother breastfeed, and viewing another child’s or adult’s nudity (Kellogg, 2009).

Five to 9 Years Old

School-age children continue to have a high level of curiosity about sexuality, their bodies, and their environment. They are aware of the pleasure stimulation gives and continue to actively seek autoerotic arousal for enjoyment. Again, reassure parents that this behavior is not associated with sexual fantasies. Contacts with other children may give them new ideas about sex, and sex games are typical (e.g., playing house or doctor) between same-age children, either of the same or opposite sex. This is normal behavior as long as a child is not emotionally distraught by the encounter or if it involves one child who is older than the other. Parents should avoid being overly alarmed if they witness this play. It is appropriate for parents to redirect the play to other activities. They should then discuss the situation later with their child to explore the experience, ascertain if the child was uncomfortable, and again emphasize the notion of privacy and respect for one’s body. Box 18-1 discusses sexual actions beyond self-stimulation and sex play that can indicate possible sexual abuse.

By 5 to 7 years old, the use of sexual or “potty” language becomes evident, often to test parental reaction. Children at this age identify more with the same-sex parent; they tend to cluster into same-sex groups if given the opportunity. They are curious about where babies come from.

By the time children are about 8 years old they begin to understand the significance of sexuality. They learn more about their body and body functions, “giggle” with children of their same sex when talking about sexuality, perhaps because they conceive that sex is a secretive topic. Unless parents actively communicate with their children, sexual lessons will be learned from peers, the media, jokes, and movies.

Some children may begin pubertal changes during this time and may be embarrassed by them. Acne, oily skin, and sweating may occur. As their bodies change they become curious and want to see others’ bodies. Masturbation is still a normal way for them to explore their bodies. Sexual language is often used more to insult others or appear smart in front of their friends.

Parents and teachers are in key positions to teach children that their sexual curiosity and feelings are normal, to help boys and girls better understand how sexual development is an integral part of growing up, to use respectful language, and to reinforce that they are always available for questions. Simple discussions about the body can introduce further discussions about hormones and reproductive systems. Establishing a good history of communication about sexuality and other subjects lays the groundwork for being accessible to update information as the child matures. This is also a good time for parents and others to reinforce the notion that there is diversity in families within which parents and adults love and care for children.

Preadolescence

Preadolescence is marked by the onset of pubertal changes. About this time, children understand sexuality as a normal part of life. Both males and females understand the changes that are occurring in each others’ bodies and by 10 to 12 years of age are ready to discuss sexual behavior and reproduction. Self-stimulation as a result of sexual reflexes may now become connected to sexual fantasies, sexual behavior, and sexual relationships. It is still common for preadolescents to socialize and develop close relationships mostly with members of the same sex. Both sexes often become uncomfortable or embarrassed about the changes in their bodies, particularly girls because breast development is more obvious to others. Privacy becomes more important.

Parents should discuss menstruation before it occurs so as not to cause undue alarm and have the child be caught “off guard.” Being mindful of their values and beliefs, parents should discuss abstinence, STIs (including HIV), birth control, the human papillomavirus immunization for both sexes, consequences of early sexual activity (including teen pregnancy), and the influence of peer pressure. This is also a good time to discuss sexual orientation.

Adolescence

Adolescence is a period of rapid physical, emotional, and social change that presents a developmental challenge to both children and parents. In terms of sexuality, adolescents fit their sense of sexual being into their evolving self-image and personal identity; they learn about their bodies’ (sometimes unexpected and embarrassing) sensual and sexual responses to stimulation, and they develop a sense of the moral significance of sexuality. Recent studies provide differing ages when adolescents report experiencing their first sexual intercourse in the U.S. (at 14.2 years [Tu et al, 2009] or at about 17 years [Guttmacher Institute, 2011]). Seventy percent of both sexes will have had sexual intercourse by the time they reach their 19^th birthday (Guttmacher Institute, 2011).

Privacy is essential for the adolescent to explore this emerging self. Activities such as group social functions, dating, participation in sports, and interactions at work and school provide opportunities to learn social and interpersonal skills of intimacy.

Learning how to communicate about sex, how to set limits, how to prevent misunderstandings, and how to say yes or no are important skills for adolescents. Equally important is the process of developing a set of sexual values. Whether the adolescent practices abstinence, has a double standard for men’s and women’s sexual behavior, or is exploitative or nurturing in close personal relationships is a reflection of the adolescent’s sexual values.

Sexuality in Individuals With Intellectual and Developmental Disabilities

The sexual development of youth with intellectual and physical developmental disabilities (I/P/DD) is the same as those without such physical or cognitive limitations. The clinician needs to focus on the developmental level rather than chronological age when determining appropriateness of sexual behavior. For example, an individual with a cognitive level of a preschooler will normally exhibit sexual behaviors consistent with that developmental level.

The provider must also recognize that I/P/DD individuals have the same desires to make decisions and foster fulfilling relationships with others. Their abilities to develop healthy sexual identities and engage in sexual behaviors often largely hinge on society’s comfort and proactive support concerning their right for healthy sexual expression, rather than on their disability itself. Individuals with I/P/DD may be viewed by society (including health providers, teachers, and parents) as being childlike, asexual, sexually inappropriate, having uncontrollable sexual urges, or being sexual deviants. Institutional isolation, overprotection, lack of awareness by others of their sexual needs, and pessimism about their potential often ends up inhibiting the healthy sexual and psychosocial development of these individuals. As a consequence, many people with disabilities are vulnerable to sexual abuse and exploitation by those who house, employ, and take care of them. A person with a disability is three times more likely to be a victim of physical and sexual abuse; those with intellectual and mental disabilities are more vulnerable (WHO and United Nations Population Fund [UNPF], 2010). This victimization can lead to low self-esteem, anxiety, depression, and adjustment disorders (Murphy and Elias, 2006).

People with I/P/DD largely acquire their sex education from formal educational programs and the media rather than from family or friends. Females may obtain such education in the form of abuse. These individuals are less likely to share their thoughts, feelings, and experiences with family and friends (Ailey et al, 2003). Unless healthy sexuality is taught and supported, unhealthy and abusive sexuality can occur. Sex education can be effective for those with I/P/DD, and topics should include those listed in Box 18-2. The depth and length of discussion should vary depending on the type of disability (e.g., sex education taught to a child with autism would have a different focus than that taught to a child with Down syndrome). Excellent resources and books for parents, teachers, and clinicians can be accessed from Planned Parenthood, SIECUS, and the National Dissemination Center for Children With Disabilities (NICHCY).