Prim Care Clin Office Pract 34 (2007) 275–292

Sexuality in the Child, Teen, and

Young Adult: Concepts for the Clinician
Helena Fonseca, MDa, Donald E. Greydanus, MDb,c,*
a
Faculty of Medicine, University of Lisbon, Lisbon, Portugal
b
Pediatrics & Human Development, Michigan State University College of Human Medicine
c
Michigan State University/Kalamazoo Center for Medical Studies, 1000 Oakland Drive,
Kalamazoo, MI 49008-1284 USA

Sexuality begins at birth or even at conception. Freud described five

psychosexual stages of development (Box 1) [1,2]. According to Freud’s
psychoanalytic theory, the Oedipus and Electra complex is described as boys
and girls having competitive feelings toward their fathers and the mothers,
respectively. Children view the same-gender parent as a rival for the attention of
the other parent. This complex is resolved when boys and girls develop normal
identification with fathers and mothers, respectively. The complex is typical
during the phallic stage and the genital stage. Moreover, according to this theory,
the development of normal sexual health dictates successful resolution of this
complex.

Normal development of sexuality

Infancy
During the first year of life (infancy), exploration is through mouthing and
sucking. Trust in a caretaker (usually the mother) is critical for healthy
development of infants. Babies start building their sexuality by touching and
being touched. The quality of this first relationship has an impact on their
emerging sexuality and is a determinant for their future sexual life.

Toddler period
During the toddler period (ages 2 to 3 years), children develop new mobility
and language skills. They learn what boys and girls are expected to do

* Corresponding author. Michigan State University/Kalamazoo Center for Medical Studies, 1000
Oakland Drive, Kalamazoo, MI 49008-1284.
276 FONSECA & GREYDANUS

E-mail address: greydanus@kcms.msu.edu (D.E. Greydanus).

0095-4543/07/$ - see front matter 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.pop.2007.04.015 primarycare.theclinics.com
Box 1. Psychosexual stages of Freud
1. Oral (birth through 1 year of age)
2. Anal (1 year through 3 years of age)
3. Phallic (3 years through 6 years of age)
4. Latency (6 years through 9 years of age) 5.
Genital (9 years through adolescence)

and the names of body parts. Self-genital manipulation for pleasure is common.
During this time, health professionals should begin providing sexual education
and guidance for families. Children’s normal curiosity about their body and the
differences between boys and girls should be anticipated. It is important to use
correct terms for all body parts, including genitals. Questions, for example,
‘‘where babies come from,’’ always need to be answered by parents or guardians
in a developmentally adequate way.

Preschool period
During the preschool period (ages 3 to 5 years), children develop further
curiosity about the differences between boys and girls and continue to have an
interest in masturbation. The manner in which parents deal with their children’s
increasing sexual curiosity influences the incorporation of sexuality into
children’s self-value. At this stage, health care professionals should provide
guidance to parents that children’s sexual curiosity and exploration are normal.
Parents should begin to teach children about sexuality through the use of age-
appropriate sex education picture books. Children need to understand that
certain parts of the body are private and should not be touched without their
permission. Questions asked by children should be answered at a level
appropriate to their understanding. Children should be encouraged to feel
comfortable asking additional questions in the important arena of sexuality.

Latency
During the latency period (age 5 to the beginning of puberty), school-age
children are expected to establish their gender identity. This latency stage, as
Freud defined it, is characterized mainly by having same-gender friends, and
sexuality often is expressed by a major interest in sexual jokes, stories, or songs.
They are curious about the anatomy of the opposite gender. Nevertheless,
usually, masturbation recedes during this period.
Parents should have age-appropriate sex education books at home that help
answer some questions and encourage children to ask further questions. If
 SEXUALITY IN THE CHILD, TEEN, AND YOUNG ADULT 277

children are receiving sex education at school or in the community, parents

should discuss this information with them to be sure the children understand the
parents’ views. Parents of girls should start to prepare their daughters for
menstruation. The transition into adolescence is characterized by a reinforced
interest regarding sexuality.

Adolescence
Adolescence is a critical period of psychologic and physical growth and
pubertal development. A key component to the healthy development of
adolescents is how they proceed with the stages of adolescent sexuality. The
progression through puberty is predictable, but there is considerable variation in
its onset, timing, and magnitude of changes. Peer relationships play a major role
in adolescents’ emotional separation from parents and emerging individuality.
Peer and social influences may expose adolescents to values that differ
significantly from their family’s values. There is a need to balance peer pressure
and family expectations, and sometimes conflicts may arise. Adolescents’
struggle to gain autonomy often is a source of family tension. Parents may
describe this period as a critical and challenging one for the family. A family
physician can be a key person in this process, offering guidance and support for
adolescents and families as they adapt to these changes [3].
The sequential changes of puberty are classified in five stages, the Tanner
stages (also called the sexual maturity stages) (Tables 1 and 2) [4]. Breast buds
(thelarche) are the first clinical event of puberty in females and represent a
sexual maturity rating (SMR) of 2. Menarche (onset of menstruation) happens in
SRM 4, between 12 and 13 years of age in the average pubertal female;
menarche may occur in a late SMR 3 stage. In males, the first clinical event of
puberty is enlarged testicles (over 4 mL in volume). Ejaculation is noted at SMR
3.
Female adolescents may be concerned about vaginal discharge (physiologic
leukorrhea). Male adolescents may be concerned about spontaneous erections or
nocturnal emissions. Transient development of breasts (gynecomastia), which
happens in approximately two thirds of male adolescents by Tanner stage of
SMR 2 to 3, also can be a source of confusion and anxiety for males. Female
and male adolescents may be concerned about homosexual interests, sexual
experimentation, and pressure from peers and society to become sexually active.
In both genders, acne, body odor, and seborrheic dermatitis may have a negative
impact on body image and decrease self-esteem.
For adolescents who mature early (ie, precocious puberty) or late (ie, delayed
puberty), there can be considerable psychosocial consequences. An association
between early maturation and earlier onset of sexual intercourse is documented
[4]. Moreover, it is shown that young women who mature early have higher
rates of psychopathology and, thus, are at unique risk for persistent difficulty
during adolescence; they should be targeted for preventive efforts [5]. It also is
278 FONSECA & GREYDANUS

noted that bulimic-type eating pathology among girls is

Table 1
Sexual maturity rating or Tanner staging in females
Stage Breasts Pubic hair Range
I None None Birth to 15 years
IIa Breast bud (thelarche): Long downy pubic hair near 8.5 to 15 years (some use
areolar hyperplasia with the labia; may occur with 8 years)
small amount of breast breast budding or several
tissue weeks to months later
(pubarche)

IIIb Further enlargement of Increase in amount of hair 10 to 15 years

breast tissue and areola with more pigmentation

IVc Double contour form: Adult type but not distribution 10 to 17 years
areola and nipple form
secondary mound on
top of
breast tissue
Vd Larger breast with singleAdult distribution 12.5 to 18 years
contour form
a
Peak height velocity often occurs soon after stage II. b
25% develop menarche in late III.
c
Most develop menarche in stage IV 1 to 3 years after thelarche. d 10%
develop menarche in stage V.
Reproduced with permission from Greydanus DE, Fonseca F, Pratt HD. Childhood and
adolescent sexuality. In: Behavioral pediatrics. 2nd edition. Lincoln (NE): iUniverse Publishers;
2006. p. 308–10.

associated with early menarche and early sexual experiences [6]. Alternatively,
girls who mature late may be teased more frequently by their peers than other
youth and be an object of bullying at school [7].

Psychosocial development
Adolescent psychosocial development typically is divided into three periods:
early (ages 10 to 14), middle (ages 15 to 17), and late adolescence (ages 18 to
21þ) (Table 3). Early adolescence is characterized mainly by feelings of
confusion because of the rapid physical changes, exploration of one’s own body,
and need for comparison with peers of the same gender due to concerns about
normality. Much energy is spent acquiring social skills and interacting with
individuals of the same gender. In this interaction, however, adolescents’
interests come first and concerns of others become secondary.
Early adolescents behave as if they are the only actor on the stage of life.
According to the psychoanalytic theories, this period typically is the time for re-
emergence of the Oedipus complex [2]. Many young adolescents do not have
accurate information about sexual development and the consequences of early
 SEXUALITY IN THE CHILD, TEEN, AND YOUNG ADULT 279

and unprotected sexual activity. Anticipatory guidance by clinicians

Table 2
Sexual maturity rating or Tanner staging in males
Stage Testes Penis Pubic hair Range
I No change, testes Prepubertal None Birth to 15 years
2.5 cm or less
II Enlargement of Minimal or no Long downy hair 10 to 15 years
testes, increased enlargement often occurring
stippling, and several months
pigmentation of after testicular
scrotal sac growth; variable
pattern noted with
pubarche
IIIa Further enlargement Significant penile Increase in amount, 10.5 to 16.5 years
enlargement, now curling
especially in length

IVb Further enlargement Further enlargement, Adult type but not Variable; 12 to 17
especially in distribution years
diameter

Vc Adult size Adult size Adult distribution 13 to 18 years

(medial aspects of
thighs, linea alba)
a
Peak height spurt usually between III and IV. b
Axillary hair develops and some facial hair.
c
20% have peak height velocity now. Body hair, increase in musculature, and so forth con-
tinue for several months to years.
Reproduced with permission from Greydanus DE, Fonseca F, Pratt HD. Childhood and
adolescent sexuality. In: Behavioral pediatrics. 2nd edition. Lincoln (NE): iUniverse Publishers;
2006. p. 308–10.

must include a talk with the adolescents about body changes during puberty,
including individual variations in the rate of growth and development [1,4].
Middle adolescence is characterized by the acquisition of diverse
experiences, typically short and intensive, with the opposite gender. At an early
stage, it begins with interest in the opposite gender, then group dating,
individual dating, and, finally, eventual sexual intimacy in many adolescents.
These relationships mainly are narcissistic, generated from self-interest.
Anticipatory guidance by clinicians should address adolescents’ concerns while
also providing information on sexual development, contraception, and
prevention of sexually transmitted diseases (STDs) [1,4]. Moreover, parents and
health professionals should discuss with adolescents ways to resist sexual
pressures. According to the resilience theories, the identification of a supportive
adult who can give adolescents accurate information about sexuality is
important [1]. Health supervision must address sexual experimentation, its risks,
and prevention of negative results.
280 FONSECA & GREYDANUS

Late adolescence is characterized by building relationships that are more

adult-like. The ability to integrate emotional and physical intimacy in a love
relationship is an important developmental task for older adolescents and young
adults. Anticipatory guidance by clinicians should include a talk about sexual
maturity and sexual feelings (for the same or opposite gender), contraceptive
methods, and sexually transmitted disease prevention [1,4].

Table 3
Adolescent psychosocial development
Early adolescence Middle adolescence Late adolescence
(11–14 years) (15–17 years) (18–25 years)
Concrete thinking: Early abstract Abstract thinking:
Cognitive thinking
here and now. thinking: inductive/ adult ability to
Appreciate deductive think abstractly.
immediate reactions reasoning. Able to Philosophic.
to behavior but no connect separate Intense idealism
sense of later events, understand about love,
consequences later consequences. religion, social
Self-absorbed, problems
introspective, lots
of daydreaming
and rich fantasies

Task areas
Transition from Insistence on Emancipation
1. Familyd independence
obedient to independence, privacy (leave home)
rebellious May have overt Re-establishment of
Rejection of parental rebellion or sulky family ties
guidelines withdrawal Assume true adult
Ambivalence Much testing of limits roles with
about wishes Roleplaying of commitment
(dependence/ adult roles (but
independence) not felt to be
Underlying need to
‘‘real’’deasily
please adults Hero
abandoned)
worship
(‘‘crushes’’)
Same-gender ‘‘best Dating, intense interest Partner selection
2. Peersdsocial/ sexual
friend’’ in ‘‘boys’’ Realistic concept of
‘‘Am I normal?’’ Sexual experimentation partner’s role
concerns begins Mature
Giggling boy-girl Risk-taking actions friendships
fantasies Unrealistic True intimacy
Sexual concept of possible only after
experimentation partner’s role own identity is
not normal at this Need to please established
age: done to significant peers (of Need to please self
counteract fears of either sex) too (‘‘enlightened
worthlessness self-interest’’)
 SEXUALITY IN THE CHILD, TEEN, AND YOUNG ADULT 281
Obtain ‘‘friends’’
Humiliate parents
(continued on next page)
Table 3 (continued)
Early adolescence Middle adolescence Late adolescence
(11–14 years) (15–17 years) (18–25 years)
Still in a More class choices in Full-time work or
3. Schooldvocation
structured school setting college
school setting Beginning to Identify realistic
Goals unrealistic, identify skills, interests career goals
changing Start part-time jobs Watch for apathy (no
Want to copy favorite Begin to react to future plans) or
role models system’s alienation, because
expectations: may lack of goal-
decide to beat the orientation is
establishment at its correlated with
own game unplanned
(super achievers) or pregnancy, juvenile
to reject the game crime, and so forth
(dropouts)

4. Self-perception Incapable of Confusion about self- Realistic, positive

selfawareness while image self-image
still concrete
thinkers
Identity Losing child role but Seek group identity Able to consider
do not have Very narcissistic others’ needs, less
adult role; hence, low narcissistic
self-esteem
Social responsibility Tend to use denial (it Impulsive, impatient Able to reject group
can’t happen to me) pressure if not in
self-interest
Values Stage II values Stage III values Stage IV values
(back-scratching) (conformity) (social
(good behavior in (behavior that peer responsibility)
exchange for rewards) group values) (behavior
consistent with
Chief health issues (other Psychosomatic Outcomes of driving)
than acute symptoms sexual Crisis counseling (runaways, actingout, family, and
illness) Fatigue and so forth)
‘‘growing pains’’ laws and duty)
Concerns about Health promotion/ healthy lifestyles
normalcy Contraception and STD/AIDS prevention
Screening for Self-responsibility for health and health care
growth and
development
problems
experimentation
Prevention of pregnancy, STDs,
AIDS
(continued on next page)
Health-risk behaviors (drugs, alcohol, and

Table 3 (continued)
282 FONSECA & GREYDANUS

Early adolescence Middle adolescence Late adolescence

(11–14 years) (15–17 years) (18–25 years)
Professional approach. Firm, direct support Be an objective Allow mature
To retain sanity, you sounding board (but participation in
Convey limitsd simple,
and your staff let them solve own decisions
concrete choices
should: problems) Negotiate Act as a resource
Do not align with choices Idealistic stage, so
Like teenagers
parents, but do be Be a role model convey
Understand development
an objective caring Don’t get too much ‘‘professional’’
Be flexible
adult history image Can expect
Be patient Encourage (‘‘grandiose patients to examine
transference (hero stories’’) underlying wishes,
worship) Confront (gently) motives (eg,
Sexual decisionsd about pregnancy wish if
directly encourage to consequences, poor compliance
wait, to say responsibilities with
‘‘NO’’ Encourage Consider: what will contraception)
parental presence give them status in Older adolescents
in clinic, but eyes of peers? able to adapt to
interview teens Use peer-group policies/needs of
alone sessions clinic system
Adapt system to
crises, walk-ins,
impulsiveness,
‘‘testing’’
Ensure
confidentiality
Allow teens to seek
care independently

From Greydanus DE, Fonseca F, Pratt HD. Childhood and adolescent sexuality. In: Behavioral
pediatrics. 2nd edition. Lincoln (NE): iUniverse Publishers; 2006. p. 308–10; with permission.
Courtesy of Roberta K. Beach, MD, Denver, CO.

Researchers have shown considerable differences between genders

concerning the way they view sexuality [8]. Western society conditions men at
an early stage of their development that dominance, aggressiveness, and
achievement are synonymous with masculinity. Alternatively, contraceptive
responsibility remains a female responsibility instead of a shared one for
heterosexual couples. Lack of role models, the influence of the media, and
exposition to limited or inadequate sexual education may explain some conflict
and confusion regarding sexuality and gender roles in men.
The media are believed to play a significant role in encouraging early sexual
activity among adolescents [1,7]. Adolescents rank the media second only to
school sex education programs as a leading source of information about sex [9].
The dramatic changes that have occurred in contemporary families are partially
responsible for that [7]. Most parents have a decreased amount of time to spend
 SEXUALITY IN THE CHILD, TEEN, AND YOUNG ADULT 283

with their adolescents, leading to decreased communication and support. At the

crucial period in development, when adolescents are likely to experiment with
behaviors that can have serious health consequences, parental involvement and
supervision are needed more than ever. Primary care physicians can play an
important role in helping families adapt to relationship changes between parents
and changing adolescents while maintaining a balance that provides parental
supervision and promotes adolescents’ normal autonomy [1,7].

Adolescent sexual behavior

Oral sex
As adolescents experiment with their sexuality, oral sex becomes a common
practice, often without understanding that several STDs may result (Box 2) [10–
12]. A survey of 212 adolescents in the tenth grade identified 42% of the female
adolescents and nearly 38% of the male adolescents reporting oral sex behavior
in contrast to 35% of these female adolescents and 22% of these male
adolescents involved in coital behavior [10]. In a survey of 580 ninth graders,
nearly 20% had been involved in oral sex in contrast to 13.5% with coital sex
[11]. Youth involved in oral sex often feel it is safer than coital sex.

Coital sex
The Centers for Disease Control and Prevention’s 2005 Youth Risk Behavior
Surveillance notes that 46.8% of all high school students have had sexual
(coital) experience, with a range of 43% for whites, 51% for Hispanics, and
67.6% for African American youth [13]. In addition, 33.9% currently are
sexually active (ie, have had sexual intercourse during the 3 months preceding
the survey). This report notes that nationwide, 6.2% are coitally active before
age 13 (8.8% of males and 3.7% of females), and 14.3% of youth have four or
more partners (16.5% of males and 12% of females) [1,13]. Youth who have
experience with more than one partner usually

Box 2. Sexually transmitted microbes spread by oral sexual behavior

Herpes simplex virus
HIV/AIDS
Human papillomavirus Neisseria gonorrhoeae
Treponema pallidum
practice serial monogamydhaving one partner and then moving on to another,
usually one at a particular time [14]. There is an increased coital rate with
increased drug or alcohol use and those engaged in survival sex. In the United
States, millions of coitally active youth produce approximately
284 FONSECA & GREYDANUS

900,000pregnancies andmore than 6million cases of STDseachyear [1,7,15].

Adolescent pregnancy
Approximately 900,000 adolescent pregnancies are reported annually in the
United States [16,17]. A decrease in adolescent pregnancies was noted from
1973 (the date of legalized abortion in the United States) until 1986; there was
an increase from 1986 until 1991, and then a decrease until the present.
However, 40% of female adolescents still become pregnant at least once.
Female adolescents present 13% of all United States births (4,158,212 in 1992)
and 26% of all abortions (approximately 400,000) [18].
The 2005 birth rate of 40.4 per 1000 female adolescents ages 15 to 19 years
in the United States is the highest among all developed nations and is in stark
contrast to a birth rate of 4 per 1000 in Japan; rates lower than the United States
are noted in Canada, Great Britain, France, Sweden, and other countries [19–
21].
In the United States, 14% of adolescent pregnancies end in miscarriages, 51%
in live births, and 35% in abortions. In 2005, approximately 20% of births to
adolescents were not first births, representing a 7.5% increase in repeat
childbearing during adolescence since 1985. The 2005 data reveal a birth rate of
60.9 per 1000 female adolescents, ages 15 to 19, in the African American
population versus 26 for 15- to 19-year-old white, 81.5 for Hispanic, 52.7 for
American Indian, and 16.9 for Asian American, or Pacific Islander mothers 15 to
19 years old [20,22].

Summary
Limited sexuality education can be invoked as a partial explanation for the
tragic statistics of American adolescent sexuality (ie, high rates of STD, sexual
assault, and unwanted pregnancy) noted throughout the United States
[14,15,17,18,23–30]. Simply discouraging or banning sexuality education on
cultural and religious bases does not resolve these issues fully, if these youth are
sexually active. Limited knowledge of sexuality can be dangerous for the youth
of America and of the world [27–31]. Concepts of sex education are presented in
Appendix 1. Adolescents should be taught that abstinence is an important goal
while they are preparing to become adults [29]. They also can be taught several
strategies to prevent negative consequences of sexual behavior:
1. How to avoid sexual abuse
2. How to resist unwanted sexual advances (including ‘‘date rape’’)
 SEXUALITY IN THE CHILD, TEEN, AND YOUNG ADULT 285

3. How to negotiate peer pressure

4. How to avoid media messages for sexual
behaviorwithout responsibility.
Teenagers who are mothers or fathers should receive parental, school, and
societal support to become the best possible parents and to reduce potential
negative consequences of teenage pregnancy [1,15,18]. Pregnancy prevention
programs should be tailored to the needs of each region, involving
multidimensional solutions. Cultural and religious beliefs of each person must
be respected [29].
Adolescents who become sexually active must be taught how to use
contraceptives effectively (‘‘safe sex’’) and receive access to contraception,
including emergency contraceptives [28–35]. Clinicians should encourage
immunization with the human papillomavirus vaccine and ensure that the
hepatitis B vaccine is provided. Adolescents also can be taught about the
dangers from sexual abusers found on the Internet and the problems that
bullying present to many youth [36–38]. Many dangers await children,
adolescents, and young adults as they traverse the normal stages of human
sexuality. Family physicians can be a helpful guide in this regard, with positive
lifelong results for these important patients.

Appendix 1

Anticipatory guidance: sex education

Age Children’s needs or interests Anticipatory guidance

Newborn Cuddling, sucking, loving Teach parents the importance of touch,
touch (foundations for of warm, loving cuddling
security, trust and later Encourage breastfeeding, front packs,
ability to give physical rocking chairs
affection are established
‘‘You can’t spoil a baby at this agedit’s
now)
okay to pick her up when she cries’’
Observe parents’ interactions with
newbornddemonstrate behaviors if
parents seem uncomfortable

Comment on role expectationsdby

choosing ‘‘pink or blue’’ we are
already sending gender role messages
to infants
286 FONSECA & GREYDANUS

Appendix 1 (continued)
Tell
Age Children’s needs or interests Anticipatory guidance
6 months Infant discovers body Self- parents to expect this behavior and
stimulation and touching of that it’s normal
genitals Ask parents about their own attitudes
toward infant self-stimulation
(continued on next page)
1 year Curiosity as to what them the vocabulary to use
daddy and mommy look
Encourage questionsdlet them know
like without clothes on
sexually related topics are appropriate
Remind them, ‘‘Don’t slap his hands,’’ as this
to discuss during health care visits
sets up negative messages (ie, that part of
Guidelines for household nudity.
your body is ‘‘bad’’)
Explore parents’ own attitudesd what’s
Show the parents the parts of genitaliadteach
best is what they are
3–5 years Children need answers level of
to ‘‘sexual questions’’ development learn
appropriate to cognitive correct words for
genitals and body
1.5–3 years Self-respect and self-esteem functions (penis,
develop. vulva, bowel
Feelings form about being a movement)
boy or a girl comfortable with
Effectiveness of toddler Children begin to establish gender
discipline at this age identity by observing differences in
determines later ability to male and female bodies
handle frustration and Use picture books if nudity is
have self-control uncomfortable
Exploration of body parts is Parents should avoid messages that
common convey nudity as ‘‘dirty’’ or
Bathroom activities are of ‘‘pornographic’’
great interest (toilet Teach parents how self-esteem is
training) developed. Need for lots of positive
Sense of privacy develops feedback (‘‘catch them being good’’).
Give praise and positive messages
about being either a girl or a boy. Let
children seek own preferences for
gender role behavior (okay for boys to
play with dolls or girls to play with
trucks)
Discuss plans for discipline. Teach
parents methods (eg, time out).
Emphasize how to give positive
reinforcement (‘‘I like it when you__’’)
Encourage parents to help children
 SEXUALITY IN THE CHILD, TEEN, AND YOUNG ADULT 287

Appendix 1 (continued)

Age Children’s needs or interests Anticipatory guidance

Discuss toilet private, and how to show respect for
others
trainingdusing rewards
Give techniques for determining level
and reinforcing positive
of understanding (‘‘where do you
attitudes about genitals
think they come from’’)
Tell parents to expect
Children need to learn it’s okay to talk
sexual questions (‘‘where
about sex
do babies come from’’)
Give booklets or suggest additional
and give examples of
educational materials
how to answer them
Prepare parents for children’s
(continued on next page) seductive behavior
Grasping genitals clearly Encourage parents to support each
is pleasurable, may occur when children other and put their needs as a couple
are upset first (bad time to get divorced)
Children become very seductive toward Remind them to role model the kind of
opposite-gender parent Role-modeling male-female relationship they want
(assimilation of characteristics of same-gender their children to imitate
role model) takes place (because the kids will)
Children begin learning what is socially This is the time to begin
acceptable, what behaviors are public or
5–7 years ‘‘Playing doctor’’ is and men are
universal equally
Kids have learned responsible for
parents’ discomforts, outcomes
starting ‘‘keeping Let parents know that childhood genital
secrets’’ about sex exploration is typicaldit satisfies
Peer discussions provide
curiosity about opposite gender
many ideas about
Ask parents about their own
sexddirty jokes among childhood experiences ‘‘playing
playmates common doctor’’
Four-letter words (for Discuss ways to handle the situation
exhibitionist behavior)
(‘‘It’s normal to be curiousdwe
used for shock value
consider other people’s bodies privated
Starting schooldso
I’d like you to get dressed and play
stranger awareness is
other games’’)
important
Same with four-letter words
demonstrating that
(‘‘be cool’’)
women have rights
288 FONSECA & GREYDANUS

Appendix 1 (continued)

Age Children’s needs or interests Anticipatory guidance

Encourage parents to bring up sexual questions, rather than waiting
7–9 years Children need answers to
more advanced sexual
questions (often scientific)
(eg, ‘‘How does the baby
get into the womb’’) to be
asked, use ‘‘teachable
moments’’ to reinforce that
it’s okay to talk about sex.
Need ample family
discussion to balance what
is learned from playmates
Discuss sexual molestation
as a riskddiscuss
prevention techniques to
teach children Ask if
parents have been getting
any sexual questions (if
not, children may feel it’s
not okay to ask). Dispel
myth that information
leads to sexual
experimentation or
(continued on next page)
289 FONSECA & GREYDANUS

Appendix 1 (continued)
[or
Age Children’s needs or interests Anticipatory guidance good]
Need preview of changes in is an opinion, with which others may
sexual development that will not agree)
be associated with puberty Important to teach children the family
Values are instilled now that values and beliefs, as well as facts
will last a lifetime (eg, self- By now, caregivers should start giving
responsibility, kindness) anticipatory guidance directly to young
that children are ‘‘too teens and to parents
innocent’’ to hear about sex Parents need to understand the normalcy
Encourage them to use of preadolescent sexual concerns and
experiences, such as TV be willing to discuss them in a
shows, mating animals, new nonjudgmental way (last chance to be
babies in neighborhood, as an important source of
opportunities to bring up
questions informationdlater it will be peers)
Assure parents it’s okay not to Empathize with parental discomfort
know all the answers. Guide (‘‘sometimes we feel uneasy talking
them to about sex, butd’’)
resources (books) for
Model nonjudgmental ways of asking
information Give parents an
questions (‘‘some parents don’t mind
understanding of wide range of
their children looking at Playboy, and
pubertal development (eg,
some parents disapprove. What are
10–12 years Pubertal changes are of great your feelings about that?’’)
importancedhormone levels rise Parents must set aside time to talk with
Both genders need to know about children about puberty and sexual
body changes, menarche, wet changes
dreams, and sexual fantasies School and community groups (scouts,
Gender behavior church) should be encouraged to
‘‘rehearsal’’ is common provide sex education for young
(looking through adolescents
Playboy, spin-the-bottle games) (continued on next page)
Questions about homosexuality
arise Build self-esteemdpreteens need lots of
Need for privacy intensifiespositive feedback
Self-esteem is fragile At puberty, parents will reap the
results of their past efforts
Parents need to learn how to ‘‘let go with
love’’ and let teens take responsibility
breast budding at age 8–9 isfor choices
normal) Reflective listening is far more important
Encourage parents to teachthan talking
difference between factsAffirm
and wholesomeness of sexual feelings
opinions (eg, that nearly (‘‘it’s
all natural to want to have sex’’)
young men masturbate iswhile
a conveying own opinions (‘‘it
fact; that masturbation iswould
bad be wiser to wait until you’re
 90 FONSECA & GREYDANUS

Appendix 1 (continued)
sure’’) 15–17 years Sexual activity begins Ask parents, ‘‘W
Parents should be sure teens have access (middle Services for sexual issues prepare your tee
to educational resources (eg, books) adolescence) (family planning, STD, when the time co
that will answer questions in detail pregnancy tests) are essential have you discuss
Many heterosexual young teens have Meaning of relationships your teen?’’
some experimental homosexual is explored (‘‘Does he Encourage paren
encounters before dating. They may really love me’’) Life permission to ob
need reassurance and information planning becomes serious acquaint them w
Parents need to prepare teens to use (high-risk, lowincome means
teens need to see options Allow confident
contraceptionddiscuss realities, give
beyond pregnancy) independence fo
permission, explain about resources. Increased independence can care
Dispel parental myths (eg, that access
lead to risks Parents can cont
to family planning promotes
(date-rape, sexual assault) (‘‘What did you
promiscuity)
Sexual preference becomes that showed __?
Message should be ‘‘wait until
chance to look a
you’re sure you’re ready, then use apparent to selfdhomosexual
consequences. B
reliable birth control each and teens may feel much
either unwillingn
every time’’ confusion and self-doubt
challenges to par
Do not give messages that viewpoints
‘‘good girls’’ don’t have sexdguilt
induction leads to denial and inability Most teens do no
to accept responsibilities for choices personal sexual a
(eg, unprotected sex) parents
Risks for STDs and AIDS should be Suggest to paren
discussed openly. Help teens plan teens’ plans for t
realistically for self-protection ask how plans w
(abstinence, monogamy, and condoms) pregnancy, or m
Continue to discuss personal values
(continue to separate facts from Teens need to kn
opinions) expect them to p
Continue to reinforce positive selfesteem pregnancy, STD
have sex
(continued on next page) Discuss preventi
Age Children’s needs or interests sexual assault
Sexual orientatio
about (rather tha
Referral to suppo
helpful to gay te
emotional or soc

From Greydanus DE, Fonseca F, Pratt

HD. Childhood and adolescent sexuality.
In: Behavioral pediatrics. 2nd edition.
Lincoln (NE): iUniverse Publishers; 2006.
p. 326–30; with permission. Courtesy of
Roberta K. Beach, MD, Denver, CO.
 SEXUALITY IN THE CHILD, TEEN, AND YOUNG ADULT 291

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