DEVELOPMENT OF SEXUAL IDENTITY

Sexual behaviors occur throughout childhood. In the first few days of life male infants can have erections and female infants are capable of vaginal lubrication. During the preschool period, masturbation occurs in both sexes but is more common in boys. Between 2 and 3 years of age, children identify themselves as a boy or a girl, but the understanding that one is always a male or always a female may not develop until 4 to 5 years of age. Stating that one wants to be a member of the opposite sex and pretending to be a member of the opposite sex are not unusual behaviors in this age group. Preschool children need to begin to learn that genitals and sexual behaviors are private; it is common for preschool children to touch their genitals in public, show their genitals to others, or undress in public. It would be highly unusual for a preschool child to imitate intercourse or other adult sexual behaviors. If this behavior is occurring, the child should be evaluated for exposure to inappropriate sexual material and possible sexual abuse (see Chapter 22).

Most elementary school–age children show a strong and consistent gender identity, and their behaviors (gender roles) reflect this. If a child this age is engaging in gender role behaviors typical of the opposite sex, parents may be concerned about teasing and the possibility of their child having a homosexual sexual orientation. This concern is particularly true if a boy is engaged in effeminate behaviors that are generally viewed as less socially acceptable than a girl acting as a tomboy. By this age, dressing as a member of the opposite sex and, particularly, stating a desire to be the opposite sex are uncommon, but playing with toys designed for the opposite sex remains common. In assessing parental concerns about atypical gender role behaviors, the type of behavior exhibited and the consistency of these behaviors should be considered. Reassurance that the behavior is consistent with typical child development is appropriate when these behaviors are part of a flexible repertoire of male and female gender role behaviors. Reassurance is appropriate if the behaviors occur in response to a stress, such as the birth of an infant of the opposite sex from the child or divorce of the parents. In contrast, if these behaviors occur as a consistent and persistent pattern of nearly exclusive interest in behaviors typical of the gender role opposite that of the child’s anatomic sex, referral for evaluation for gender identity disorder (GID) would be appropriate.

The biologic, social, and cognitive changes during adolescence place a focus on sexuality. Becoming comfortable with one’s sexuality is one of the principal developmental tasks of this period and is likely to include questioning and experimentation. Almost half of high school students report that they have had sexual intercourse. Ten to 25% have at least one homosexual experience, with this behavior being reported more commonly by boys than girls. Although many adolescents have sexual experiences with a same-sex partner, only a few have a homosexual sexual orientation by late adolescence. When adolescents develop a consistent sexual orientation is probably affected by many different factors (societal, family, individual). Some adolescents report that they are certain of their sexual orientation in the early teenage years, whereas for others this does not develop until later. By 18 years of age, only a small proportion of individuals report being uncertain of their sexual orientation.

GENDER IDENTITY DISORDER

GID is characterized by intense and persistent cross-gender identification and discomfort with one’s own sex. In children, these feelings may be manifested by behaviors such as cross-dressing, stating that one wants to be or is the opposite sex, and a strong and almost exclusive preference for cross-sex roles, games, and playmates. The onset of these behaviors often can be traced back to the preschool period. However, referral for evaluation often occurs at school age, when it becomes clear that the behaviors do not represent a transient phase, and the behaviors may begin to interfere with social relationships.

In adults, GID may be characterized by a belief that one was born the wrong sex and by a persistent desire to live and be treated as the opposite sex. Adults may request hormones or surgical procedures to alter sexual characteristics to simulate the other sex. Long-term follow-up studies of children with GID suggest that only 2% to 20% have GID as adults, but persistence is more likely in adolescents with GID. Forty to 80% of children with GID have a bisexual or homosexual sexual orientation as adults. Although one must acknowledge that these children are significantly more likely to have a homosexual orientation than the general population, there is no reliable way to predict the sexual orientation of any one particular child. There is no evidence that parental behavior would alter the developmental pathway toward homosexual or heterosexual behavior (see Chapter 24).

HOMOSEXUALITY

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 alone determined sexual orientation. Some studies have found differences in the size of certain brain regions in homosexual individuals, but the findings are inconsistent. The levels of androgens and estrogens have not been found to differ in homosexual and heterosexual adults. Although it is well documented that parents tend to treat boys and girls differently, if, or how, these interactions affect sexual orientation is unknown.

It is currently estimated that about 1% to 4% of adults identify themselves as homosexual. Given the prevalent negative societal attitudes toward homosexuality, these children are at high risk for having a negative self-esteem, being isolated, being verbally harassed, and often being physically assaulted. Although sexual behaviors, not sexual orientation, determine risk of sexually transmitted infections, homosexual male adolescents engage in high-risk behaviors despite the threat of infection from human immunodeficiency virus (HIV). For medical and psychosocial reasons, health care providers need to provide an environment in which adolescents feel comfortable discussing their sexual orientation (Table 23-2).

TABLE 23-2 Providing Supportive Health Care Environments for Homosexual Youth

Ensure confidentiality

Implement policies against homophobic jokes and remarks

Ensure information-gathering forms use gender-neutral language (e.g., partner as opposed to husband/wife)

Ensure that one uses gender-neutral questions when asking about dating or sexual behaviors

Display posters, brochures, and information that show concern for issues important to homosexual youth and their families

Provide information about support groups and other resources for homosexual youth and their families

Adapted from Perrin EC: Sexual orientation in child and adolescent health care. New York, 2002, Kluwer Academic/Plenum Publishers.

Acknowledging that one is homosexual and disclosing it to one’s parents is often extremely stressful. Although many parents come to accept their child’s homosexuality, some parents, particularly those who view this behavior as immoral, may reject their child. Homosexual youth are at a high risk for homelessness. Adolescents need to be made aware that even parents who eventually come to accept their child’s homosexuality initially may be shocked, fearful about their child’s well-being, or upset about the loss of the adulthood they had expected for their child. Parents may need to be reassured that they did not cause their child to have a homosexual orientation. Likewise, they may need to be informed that therapies designed to change sexual orientation not only are unsuccessful, but often lead to the child having more feelings of guilt and a lower self-esteem. The health care provider should have knowledge of support groups and counselors who can discuss these issues with the adolescent or his or her parents when the information the health care provider offers is not sufficient.

The homosexual youth is affected by how homosexuality is addressed in schools, by peers, and by other community groups. Unbiased information about homosexuality is often not available in these settings, and homophobic jokes, teasing, and violence are common. It is not surprising that homosexual youth and adults have higher rates of anxiety and mood disorders than are found in the general population. Increased rates of substance abuse and suicide are reported. Health care providers have an important role in detecting these problems.

Although education about safe sexual practices should be part of all adolescent well-child visits, health care providers should be aware that certain sexual behaviors of homosexual males increase the risk of certain types of sexually transmitted infections. Anal intercourse is an efficient route for infection by hepatitis B virus, cytomegalovirus, and HIV. Proctitis caused by gonorrhea, chlamydia, herpes simplex virus, syphilis, or human papillomavirus may occur (see Chapter 116).