Sex,Sexuality and Gender-Related Issues in Child Psychiatric Practice: A Review

Abstract

Abstract

In child and adolescent psychiatric practice, it is important for a clinician to be aware of contexts in which children are brought with concerns related to sexual behaviors. Johnson described a continuum of natural and healthy behaviors to sexually aggressive behaviors. Sexual development begins in fetal life and continues through infancy, childhood, and adolescence along characteristic pathways. Typically, developing children exhibit a wide range of sexual behaviors. Children and adolescents may display increased or deviant sexual behavior as a result of certain stressors, traumatic experiences, or psychiatric illnesses. This has been emerging as an important clinical issue over the past few years. It is important to distinguish between normal behaviors and disordered behaviors before planning any intervention. This article summarizes the sexuality- and gender-related issues that are encountered in child and adolescent psychiatric practice.

Introduction

Sexual behaviors displayed during development vary by age: those exhibited by toddlers, school-age prepubertal children, and adolescents differ significantly. Role-playing, exploratory, and self-stimulating behaviors constitute part of the normal trajectory of sexual development. Empirical research indicates a correlation between levels of sexual behavior and social stressors such as family stress and family violence too. ¹ Johnson described a continuum of natural and healthy behaviors to sexually aggressive behaviors. ²

Sexual development begins in fetal life when brain structures that promote sexual- and gender-related functions are organized under the influence of genes and sex hormones. It continues through infancy, childhood, and adolescence along characteristic pathways. It is noteworthy that there is significant variability among individuals. ³ Typically, developing children exhibit a wide range of sexual behaviors. Behaviors can be relating to adherence to personal boundaries, self-stimulation, sexual knowledge, sexual interest, sexual intrusiveness, sexual anxiety, and voyeuristic behavior. Gender role behavior although distinct falls under the broad array along developmental lines. These behaviors were found to be correlated with demographic and family variables such as stress, being in day care, maternal education, family sexual behavior, and family violence. ⁴

Children and adolescents may display increased or deviant sexual behavior as a result of certain stressors, traumatic experiences, or psychiatric illnesses. This is emerging as an important clinical issue over the past few years. ¹ It is important to distinguish between normal behaviors and disordered behaviors before planning intervention. Various contexts in which children are brought with concerns regarding sexual behaviors for a clinical opinion are described below.

Clinical Scenarios

Clinical scenarios are broadly categorized under normal sexual behaviors, traumatic sexualization, sexual behaviors associated with neurodevelopmental conditions, sexual issues associated with psychiatric conditions, core gender-related issues, and psychiatric issues associated with medical conditions.

Normal sexual behaviors: Although part of normative development, normal behaviors when excessive to an extent that they impair daily functioning, they become pathological. Likewise, they can indicate possible sexual abuse when they are excessive and unusual, not in keeping with the normal behaviors completely.

Sexual behaviors part of normative development (childhood): Often parents panic when they notice normative sexual behaviors in children and come for help. If one is able to establish that the behaviors are part of normal trajectory of development, reassuring parents will suffice. Preschoolers exploring genitalia by touching their genitals, touching breasts of familiar adults constitutes normal behavior. Young school-aged children playing games with same-age children related to sex and sexuality is normal. Preschoolers touching adults sneakily or demanding and making others touch them inappropriately or young children forcing others to play sex and sexuality related games is abnormal. ² Possibility of sexual abuse must be ruled out in such cases and intervened accordingly following a multidisciplinary approach to ensure holistic care. Excessive self-stimulation may also indicate under-stimulation. A functional behavioral analysis must be done to identify targets and devise a management plan.

Sexuality-related issues in adolescence: One may present with excessive concern about normal sexuality or denial of obviously problematic sexuality that is identified incidentally. The former may present with worries and myths related to masturbation or issues pertaining to evolving sexual identity or sexual orientation. The latter includes those who are in denial of problematic behavior. This may include watching excessive pornography that is impairing functioning or engaging in sexting associated with boundary and privacy violations, and so on. Misconceptions about masturbation and or nocturnal emissions leads to feelings of guilt and depressive symptoms that if not addressed may cause significant dysfunction. ⁵ Children may become anxious when they are attracted to opposite gender or have feelings for same-sex individuals. Lack of adequate knowledge about sexual feelings and expression of the same in socially acceptable ways causes confusion. When integrating this into emerging identity becomes difficult, it leads to poor self-esteem. Societal sanctions and family’s unwillingness to accept homosexuality as a normal variant of human sexuality adds to the identity confusion and leads to interpersonal conflicts.

With the increase in the use of smartphones among youth and easy accessibility of internet, children and teenagers are engaging in activities such as watching pornography and sexting. There are debates over pornographic addiction as a distinct entity. Irrespective of the differing views it can have adverse mental health consequences when it impairs daily functioning. ⁶ The phenomenon of “sexting” is also on the rise. It involves the transmission of text, images, or videos containing sexual material. Its prevalence is high among teenagers. Studies indicate that this behavior may be associated with depression and impulsivity. ⁷ All these behaviors can also amount to cybercrime and raise legal and ethical questions.

Sexuality education based on sound scientific information is needed to dispel myths for those with disproportionate concerns about normal sexuality. ⁵ On the other hand, those with problematic behaviors will need more intensive interventions in addition to sexuality education, in the form of detailed evaluation exploring child’s vulnerabilities, origins of these behaviors, and factors influencing them; individual and family interventions tailored to a given child and family; and pharmacotherapy for the treatment of underlying depression and or anxiety or comorbid conditions. A multidisciplinary approach to case management helps in addressing varied concerns that include psychosocial and legal issues.

Gratification disorder: Children may display a spectrum of behavioral patterns from those mimicking seizures to genital stimulation depending on the developmental age. Still recognized the concept of infantile masturbation in 1909. ⁸ It is also known as “benign idiopathic infantile dyskinesia,” a form of a masturbatory behavior. It is often mistaken for epilepsy, paroxysmal dystonia, dyskinesia, or abdominal pain. It involves little or no genital stimulation and primarily presents as clonic movements or tonic posturing associated with grunting, facial flushing, and or sweating. These episodes last for a mean duration of 9 minutes (30 seconds to 2 hours) and mean frequency was found to be 16 times a week (once a week to 12 times a day). ⁹ Typically, this behavior peaks at 4 years of age and in adolescence. ¹⁰ It is a benign and self-limited condition, commonly recognized as a variant of normal behavior. ¹¹ A possibility of child sexual abuse should be ruled out by taking a thorough history and appropriate assessments. Home video recording helps in diagnosing the condition and preventing unnecessary investigations and interventions. ⁹ Once the diagnosis is confirmed, reassuring parents is the most effective management. ¹² Literature suggests a correlation with future attention deficit hyperactivity disorder (ADHD). ¹³

Traumatic sexualization: A child may develop sexualized behavior in the aftermath of being sexually abused. It refers to the child’s sexual feelings and behaviors that are dysfunctional leading to child displaying inappropriate sexual behavior. ¹⁴ It is important to clarify history and provide appropriate help. A child may have misconceptions and experience confusion about his/her sexual self-concept. ¹⁴ Finkelhor and Browne proposed traumagenic dynamics to understand the impact of sexual abuse on a child. Traumatic sexualization is one of the 4 trauma-causing factors. It can develop in a variety of ways and its degree varies with the abusing experiences. ¹⁴ It has a negative impact on the self-esteem especially in the domain of social and sexual relationships. ¹⁵ It can be assessed by using Trauma-Related Beliefs Questionnaire ¹⁶ : each subscale of the instrument corresponds to a traumagenic dynamic. It is imperative to provide appropriate and adequate medical, psychological, and legal assistance to the child and family. It will therefore call for a multidisciplinary approach to formulate and implement a management plan.

Sexual behavior and neurodevelopmental disorders: Parents bring children with concerns regarding issues related to expression of love and affection, modesty or gender-role performance, making inappropriate sexual advances, or violation of personal boundaries. But they may or may not voice these concerns. These issues surface while doing a systematic evaluation of the situation or addressing other problems. There is a culture of silence around this topic due to general misconceptions surrounding discussions about sexual behavior, and more so in the case of neurodevelopmental disorders. For instance, any expression of sexual behavior or interest is dangerous and needs to be stopped immediately or any talk about sexuality will lead to sexual misbehaviors. ¹⁷ In fact, this kind of societal attitudes lead to a lack of awareness and adequate skills building and training of children with neurodevelopmental disorders, which puts these children at a risk of becoming a victim to the false accusations of sexual offending too. ¹⁸

Children watch films and advertisements and many of their expectations may be formed by the influence of media. However, the opportunities to fulfill them in socially acceptable ways do not exist. ¹⁹ Families and institutions often neglect teaching them as to what constitutes acceptable and unacceptable sexual behavior and/or may tolerate inappropriate displays of affection. In a social setting it may be embarrassing. ²⁰ Moreover, these children are at a higher risk of being sexually exploited as they tend to be nonassertive and may possess poor judgment in assessing people’s motives. Also, their complaints are not always taken seriously. ²¹ Like any other behavior, sexual responses are learned, shaped, and reinforced by environment. ²⁰ Therefore, sexuality education at various levels viz. individual, group and parent-mediated, and tailor-made according to the developmental level and needs is important. Parents need to be empowered with strategies for skills training and behavior modification techniques. ¹⁷

Sexual issues associated with psychiatric conditions

Sexual obsessions in obsessive-compulsive disorder (OCD): Pediatric OCD has a prevalence rate of 2% to 4%, ²² and Flament reported a lifetime prevalence of 1.9% from an adolescent epidemiologic study. ²³ Sexual obsessions are not uncommon in children and adolescents. In a study done by Cruz et al, about a quarter of the sample aged between 8 and 17 years had sexual obsessions at baseline. Those with sexual obsessions had more severe OCD symptoms and depression than those without. ²⁴ It was also reported that sexual obsessions are more common in adolescents than adults with late-onset illness. ²⁵ Children and adolescents may be unable to concentrate in class or socialize normally because of the nature of the content of the thoughts. There are also added elements of guilt and shame. Like other obsessions these may lead to extreme anxiety and avoidance of situations that trigger these thoughts. Children may be hesitant to talk about these experiences. At times, it may be difficult to delineate the phenomenology and the presentation may be confused with psychosis, especially when insight is poor. A thorough evaluation and establishing a rapport will help to ease the situation, so their symptoms can be elicited. Children and adolescents with sexual obsessions respond to standard treatment strategies such as cognitive behavioral therapy and pharmacotherapy as required. ²⁴

Disinhibition in bipolar affective disorder: While the American Academy of Child and Adolescent Psychiatry practice parameters underscore that “diagnostic validity of bipolar disorder in young children has yet to be established,” ²⁶ a meta-analysis reported an overall rate of bipolar disorder in children and adolescents as 1.8%. ²⁷ Recent research suggests that hypersexuality may be a feature of bipolar disorder in prepubertal children and adolescents in the age group of 7 years to 16 years. ²⁸ They may present with sexual behavior that is developmentally or otherwise socially inappropriate. One may have impaired control of sexual impulses or socially inappropriate expression of sexuality associated with poor social judgment. ²⁹ Hypersexuality in this context may be intrinsic to bipolar disorder or because of psychosocial factors or due to general aggressive behavior. ³ In addition to instituting pharmacological and family interventions to manage the condition, one must do a comprehensive assessment by looking for associated problems such as suicidality, commonly comorbid disorders, psychosocial stressors, and medical problems, and devise a treatment plan accordingly. ³⁰ As for the sexual behavior per se, symptom monitoring, interpersonal skills training, and parental supervision can also help. ³¹

Core gender-related issues

Gender dysphoria (GD): Consolidation of identity development is a critical developmental goal of adolescence. However, there is lack of clarity on how gender identity and gender variance evolve. ³² While healthy children may vary in their gendered behaviors, ³³ some children may experience marked incongruence between their experienced gender and the gender associated with biological sex. The exact prevalence of GD in childhood is not known. ³⁴ At least 40% to 45% of adolescents with GD present with clinically significant psychopathology. ³⁵ Most commonly reported are depression and anxiety disorders. Self-harm and suicidal behavior are also common. It is also associated with strain in parent–child relationships, peer relationship problems, and school exclusion. ³² Gender identity problems may persist or desist. When it occurs in prepubertal age, it may resolve in some individuals by late adolescence. ³⁶ It entails interdisciplinary approach to the care of the individuals which includes psychiatric and medical management. Currently, there is no consensus regarding the best approach to clinical care of gender-diverse and transgender youth. Supportive psychotherapy and cognitive behavioral therapy for specific issues go long way in the treatment process. Pharmacotherapy can be instituted to manage comorbid psychiatric conditions. ³⁷

Psychiatric issues associated with medical conditions

Disorders of sex development (DSD): Children with DSD are generally referred by a treating pediatrician for mental health screening. DSD are a group of congenital medical conditions that affect the whole lifespan. ³⁸ They are rare disorders characterized by a discrepancy of chromosomal, gonadal or anatomic sex. ³⁹ Genital anomalies are estimated to occur at a rate of 1 in 4,500 to 5,000 births. ⁴⁰ Children with DSD are vulnerable to develop depression and anxiety disorders. It is, therefore, important to screen these children for mental health issues periodically to provide holistic care.

Conclusions

Sexual or sexuality-related concerns are not uncommon in children and adolescents. They can be the presenting complaint or be presented in association with a primary disorder. They may lie on a spectrum of normal to deviant experiences. While some conditions are apparent, others may not be so. Latter may be because of hesitancy of the family or child to talk about their concerns due to perceived stigma or lack of awareness or poor insight into the problem. Therefore, it entails a detailed assessment and thorough evaluation to come to a conclusion about the nature of the problem and manage the same.