Presently, our knowledge of children’s sexuality and sexual development can be viewed as somewhat fragmentary; empirical research has been carried out by a number of researchers resulting in a small increase in the volume of published information [1-5]. The scarcity of scientific knowledge in the area is also likely to be reflected in our present guidelines in assessments of children that display sexually problematic behaviour and in the treatment of child sexual abuse cases [6]. A problematic sexualized behaviour may also be a precursor to sexual offending [7] or a sign of underlying emotional problems [2] which is why it is so important for clinicians as well as educators and parents to be able to detect an abnormal or sexualized behaviour compared to a normal sexual behaviour, in order to help the child. The lack of previous studies of normal sexual behaviour in the age group 7-13 years was the driving force behind this study.

Most of what is known in the realm of ‘normal’ child sexual behaviour has been obtained through indirect sources such as parental reports and other mediators, or from retrospective studies of young adults [2,3,8,9]. There certainly are methodological obstacles to such research, which must rely largely on the observer’s vigilance and motivation to provide accurate information [10] and we must remember that the behaviours reported by the parents do not constitute all of the child´s sexual behaviours but those they observe and also decide to report. As the children are socialized, (the child learns which are the acceptable behaviours to be shown in different contexts) some of the behaviours may be less observable to parents or other adults [4]. Yet what can be learned represents a valuable contribution to the body of knowledge of child sexuality and for clinicians, the reports or history from the parents or other adults about the child are of great importance.

Sexual behaviours in children range from normal and developmentally appropriate to abusive and violent. The majority of sexual behaviours do not require intervention but if the behaviour is intrusive, hurtful, and/or age-inappropriate, the child may reside or have resided in a home characterized by inconsistent parenting, violence, abuse or neglect [11]. Accurate knowledge of child sexual development in children is important in many areas. For example masturbation among children could be self-soothing but could also be a result of genital infection, nappy dermatitis, parasitic disease, temporal lobe epilepsy etcetera [12]. Professionals are often supposed to be able to assess whether a sexual behaviour falls into the realm of normality or not and study results demonstrate an insecurity among both health care professionals and teachers as to what is ‘normal’ or ‘deviant’ sexual behaviour in children of different ages [13-16].

The escalating concern about childhood sexual abuse during the past 20 years has evoked a tendency to view any sexual expression in children as evidence that the child has been a victim of sexual abuse [17]. The research has therefore largely been focused on depicting the negative effects of sexual abuse, with far fewer studies focused on normative childhood sexuality, especially among younger children. A closely related area of research has been the study of sexual behaviour in normative samples of children in order to find characteristics that may establish the boundaries between ‘normal’ and ‘deviant’ sexual behaviour [2,18,19]. Results of earlier research all point to the importance of context in assessing the nature of sexual behaviour in children [1,20].

Studies of normative sexual behaviour, despite differences in methodology, do support the belief that children engage in a range of overt sexual behaviours. The form of sexual behaviours among the children varies within different cultures [5,8]. Age also seems to be a crucial factor, influencing exactly when and where children, as a result of the socialisation process and knowledge of cultural norms and taboos, learn which behaviours are accepted and which are not [17]. Studies of sexual behaviour in children (non-abused versus sexually abused children of 2-12 years of age) show that sexually abused children exhibit a greater frequency of sexual behaviour than the normative sample [5]. Freidrich [20] also claims that sexually intrusive behaviour correlates inversely with age. They further describe a peak of sexual behaviours at the age of five for both boys and girls and then dropping of over the next seven years but a slight rise at eleven for girls are noted, primarily coming from an increased interest in the opposite sex. Haugaard describes a gender difference, male collage students recalled more sexual experiences from age 7-12 years than female students did. They reported more incidents of exposing genitals and more incidents of intercourse in the same age span [13]. An American study found that intentional usage of x-rated material among boys and girls of 10-15 years of age was linked to self-reported aggressive sexual behaviour [21]. Studies show that a vast majority of children have sexual experiences with peers; between 40% and 82% has been reported, and even more have individual solo experiences [8,17]. Lamb and Coakley [22] studied females’ experiences of sexuality in childhood and found that 85 percent reported participating in a sexual game activity. A Dutch, explorative interview study of 8-9 years olds, showed that children’s own interest in sexuality is not particularly differentiated to specific body parts, and thus could be seen as an active learning process over time [6]. A normal reaction among children is embarrassment when an adult finds them playing sexual games or exploring each other. Feelings such as anger, fear and anxiety are uncommon [23].

In a previous retrospective study by Larsson and Svedin young adult respondents reported several sexual experiences during the primary school years, in solo activities and in activities with other children [24].

Studies of children’s sexual behaviour are of great importance in enhancing our knowledge about child sexual development and could also add some information about normative sexual behaviour in children in a cross-cultural perspective. Earlier research indicates that Swedish pre-school children are reported by their parents to exhibit more sexual behaviour than American children of the same age [3].

The present study aims to address the lack of knowledge in the field of normal sexual behaviour in Swedish children aged 7 to 13 years as observed and reported by their parents. This is an age when childhood sexual abuse peaks [25] and consequently it is important to provide a better basis for determining which sexual behaviours are common and which are uncommon among boys and girls. We are fully aware that child sexual behaviour is sometimes hidden from parents so what we can describe is the reported observations of the parents and not the whole truth about the sexual behaviours in this age group. Nonetheless, it is the parents´ observations and concerns that clinicians face when the parents are consulted.

Procedure

In Sweden, children begin primary school at age seven. During the study-period (2003-2004) a total of 13,290 children attended primaryschools in the middle-sized Swedish community that was selected. Six primary schools were chosen according to size and the community area where they were situated in order to get a socio-economic spread. The school authorities and thereafter the headmasters of each school gave permission to approach the teachers in the selected classes and give information about the study. Those who agreed to include their classes were given further information on the procedures, which included researchers sending additional letters to the parents. Parents first obtained a letter saying that the study was underway and that a questionnaire about their child would be sent to them shortly. A second letter outlining the background and aim of the study was sent with the questionnaire. The parents were asked to return the answered questionnaires in the enclosed pre-addressed envelope. One reminder from the researchers was administrated by the school. The response rate was 63.1%. Of the questionnaires, 66.2% were answered by the mother, 7.6% were answered by the father and 23.3% of the parents answered the questionnaire together.

Questionnaire

The first part of the questionnaire consisted of a demographic section with questions about the child and the family situation, socio-economic status and life events. In the second part, the Strengths and Difficulties Questionnaire (SDQ) used to identify strengths and difficulties in the child was included, and in the third part, a sex behaviour inventory was presented. The sex inventory questionnaire consisted of questions obtained from Friedrich’s Child Sexual Behaviour Inventory (CSBI) [19] together with questions developed for earlier Swedish studies [4,8] and revised for this study. CSBI was developed to assess children who have been sexually abused or are suspected of having been sexually abused. It has questions on nine different domains as boundary problems: exhibitionism, gender role behaviour, self-stimulation, sexual anxiety, sexual interest, sexual intrusiveness, sexual knowledge and voyeuristic behaviour. CBSI has demonstrated adequate reliability and validity [19] as well as sensitivity and clinical utility. Friedrich [19] also showed that sexual abuse characteristics were related to the CSBI total score for the child. In this study we only used the CSBI questions as a basis for frequency calculations of different behaviours in children aged 7-13 and not as a scale with subscales.

The rationale for this was the creation of a battery of questions suitable for this age group and questions such as does your child ask you questions about sex, does your child use sex-words and has your child sexually harassed other children, does your child watch pornographic movies or magazines and several questions about family habits like co-bathing, co-sleeping, were added. We did not use some of the CSBI questions such as does your child touch animals’ parts and does your child try to undress adults. The parents were asked to rate the frequency of different sexual behaviours seen in the child over the previous six months. Rates ranged from 1 = ‘never’, 2 = ‘less than once a month’, 3 = ‘1-3 times a month’, 4 = ‘at least once a week’ and 5 = ‘often/daily’ (table 2 and 3). After analyzing the answers in the first phase of the study (group 1), the research team found that some questions needed to be rephrased, some were omitted and some new questions were added in order to enhance the potential of information which could be gained from the questionnaire (group 2). The parents were also asked to give a short commentary for each observed behaviour.

Participants

General characteristics: The study included 418 children, 210 boys and 208 girls aged between 7 to 13 years at a mean age of 10.4 years (SD=1.8) (table 1). The majority of the children, 98%, were born in Sweden (94.4% in Sweden 2004, SCB). Most children, 73.6%, lived with both biological parents which corresponds with national data for this age group in Sweden, (70.6% of children aged 7-13 years old live with both biological parents 2004, SCB). Of the mothers, 30.6 % had three or more years of university studies (17.5% of the mothers of 7-13 year old children in Sweden 2004, SCB). Of the fathers, 24.8 % had three or more years of university studies (14.4% of the fathers of 7-13 year old children in Sweden 2004, SCB).

Table 1: Demographic data (n = 418).

Statistics

Differences between groups were analysed with a non-parametric test, Mann-Whitney U-test. All statistical analyses were performed using the SPSS 19.0 software package for Windows (SPSS, Inc, Chicago, IL). Significant results are presented (p<0.05) but since the risk of false discovery rate was high, p ≤ 0.01 are presented in bold figures in the tables in order to stress a higher level of significance in the interpretation of data. In the analyses of age, children were grouped in a younger group of 7-10 years of age and an older group of 11-13 years of age.

Ethical consideration

The study was approved by the Ethical Committee at the University Hospital in Linköping (Dnr 01-418).

Frequently observed and reported sexual behaviours

Four highly frequent behaviours were observed and reported by 40% or more of the parents: exploring own body and genitals, asking questions about sex, talking about sex (boys), touching genitals at home (boys). The rest of the frequent behaviours were observed and reported by three to 40% of the parents (table 2). An absolute majority of the parents did not worry about their children’s sexual behaviour (97.3%).

Table 2: Sexual behaviours among 7-13 year old girls and boys according to their parents.

Infrequently observed and reported sexual behaviour

Infrequently observed sexual behaviours were defined as behaviours reported by three percent or less of the parents. Many of the sexual behaviours we asked about were infrequently observed and reported by the parents (table 2). Eight behaviours were not reported by any parent: putting objects in the vagina or anus, oral contact with other children’s genitals, asking other children to participate in sex activities, masturbating in public (girls), sexually harassing other children (girls), being more interested in sex than children of the same age (girls), wanting to be the opposite sex (boys), and trying to kiss other children with the tongue (boys).

Other behaviours that were reported to be unusual for both sexes were: Rubbing the body against other people or objects, touching other children’s genitals, imitating intercourse with other children, showing genitals to other children, searching for clinging body contact and trying to kiss adults with the tongue.

The parents’ reports indicate that it is unusual for girls to touch the genitals in public (0.8%) and that this is somewhat more common among boys (6.3%). The parents´ reports also showed that masturbation in public is uncommon in both sexes, 1.6% of the boys and none of the girls were reported (table 2). No girls were reported as having been seen masturbating using a hand either often or daily, but 6.1% were reported as having been seen doing this infrequently, at less than once a month. Among the boys, 9.6% were reported as having been seen masturbating with their hand, 1.2% were reported as having been seen masturbating with their hand often or daily and 3.6% at least once a week.

Observed and reported sexual behaviour and gender differences

There were some significant gender differences in the study (table 2). It is more frequent that boys ask parents’ questions about sex, explore their body and genitals touch their own genitals at home and in public, use sex-words, and show genitals to adults. Girls on the other hand dress as the opposite sex more often than boys.

Observed and reported behaviour and age

We divided the sample into two age groups (7-10- and 11-13 years of age) to detect possible age differences (table 3). Behaviours decreasing with age were: examination of own genitals, touching own genitals at home, spreading one’s legs, touching own genitals in public, touching other children’s genitals, trying to or touching mothers´ or other women’s breasts. On the other hand, talking about sex increased with age.

Table 3: Sexual behaviours among 7- 10 and 11-13 year old children according to their parents.

Reported family habits and children’s interests in reproduction and the body

A minority of the children (3.7%) never hug or kiss their mother. It is more common among girls (74.4%) than boys (58.5%) to hug or kiss their mother often or even every day, (p=0.032). More than half of the girls (57.5%) but less than half (40.3%) of the boys hug or kiss their father often or everyday (p=0.31). It is more common among the boys than among the girls to never kiss or hug their father; more than one tenth (15.6%) of the boys and 5.0% of the girls never hug or kiss their father (p=0.029). It appears that mothers have a bath or a shower with the child more often than fathers. Boys (46.4%) have a bath or a shower with a parent of the opposite sex more often than girls (33.7%). The girls (63.2%) have a bath or a shower with a parent of the same sex more often than boys (55.4%). More than half of the children, 52% of the boys and 62.3% of the girls (p=0.024), shower or have a bath with a sibling. A total of 34.6% of the boys and 32.4% of the girls walked, sometimes or more often, naked at home. The parents reported that they told sons (31.2%) not to use sex-words more often than they told daughters (7.5%) (p<0.001). Two percent of the girls and 11.1% of the boys had watched pornography, according to the parents (p<0.001), and even fewer had been reprimanded after watching pornography, 0.5% of the girls and 4.9% of the boys (p=0.006). Of the parents, 93.1% stated that they had never talked with their children about masturbation (91.0% with boys and 95.1% with girls). Family habits like hugging or kissing mother (p=0.006) or father (p=0.001), having a bath or a shower with sibling (p<0.001) or parent (p<0.001), and walking around at home naked (p<0.001) were all behaviours that decreased with age.

Half or more of the children were interested in human reproduction and love and showed interest in the opposite sex with no significant difference between genders. On the other hand 10.3% of the boys talked in a negative way about the opposite sex compared with 22.5% of the girls (p=0.010) and almost 25% of both boys and girls thought the opposite sex was disgusting. At the same time, 30.4% of the boys and 41.6% of the girls asked questions about dating (p=0.029).

Almost thirty percent of the boys (29.6%) and 44.3% of the girls worried about their body (p<0.001) and 20.2% of the boys teased friends or siblings (50.0%) about their body while comparably fewer girls, 12.6% and 36.6% (p=0.005) respectively, teased a friend or sibling about their body. Some of these behaviours increased with age, such as watching pornographic movies or looking at pornographic magazines (p<0.012), and being reprimanded after watching a pornographic movie or looking at a pornographic magazine (p=0.007).

The aim of this study was to examine the prevalence of sexual behaviour in younger school children. More specifically, the aim was to investigate sexual behaviours, types and frequencies, gender and age differences, among Swedish children in the age-group of 7-13 years, as observed and reported by their parents. We have divided the reported behaviours into frequent and infrequent sexual behaviours, behaviours with gender or age differences and general behaviours. The main results of the study may be summarized in three findings.

First, our study confirmed that some sexual behaviours are common among children in this age group such as being curious about sex, which was reflected in being the most commonly reported behaviour among both boys and girls. The children questioned about sex, talked about sex, expressed or showed interest in the opposite sex and were interested in love and reproduction. Compared to behaviours reported in other studies, Swedish children in this age group showed greater curiosity about sex compared to an American study by Ott and Pfeiffer [26] in which 11-year-old children described sex as “something nasty”. On the other hand, sexual curiosity was seen among the older participants in their study while the 13-year-old adolescents expressed a desire to learn more about sexuality in general [26]. These somewhat divergent findings could of course reflect the effect of cultural differences seen in some other studies but care should be taken without knowing more about each study group [3]. Our results showed no differences concerning sexual behaviour between children of different immigrant status which might suggest that cultural differences had no major significance in our sample. On the other hand, in Moslem and Arabic cultures for example, masturbation is unmentionable and not discussed openly. It is still worse when it occurs in infants [27].

Second, many of the explicit sexual behaviours about which we asked were reported very infrequently and some behaviour was not reported at all. Some overt sexual behaviours decline with age as seen in other studies [17,18,24]. The low frequency of reported touching of own genitals in public or masturbating can, beyond the fact that parents’ opportunities to observe the behaviour is limited, be seen as a result of the normal socialization process of learning that any kind of touching genitals in public is not acceptable behaviour. Normallydeveloping children learn to be discrete and selective in the display of certain behaviours such as, for example, masturbation or touching genitals in public [12]. The infrequent behaviour is not to be seen as indicating a lack of interest in sexuality among the children but instead probably reflects the socialisation of the behaviour with increasing age as pointed out by Larsson et al. [3] and also seen in our study. The frequencies of showing and touching own genitals in public and trying to touch mother’s or other women’s breasts decreased with age. Talking about sex is a behaviour which increases with age perhaps indicating a growing interest in sex as the child grows older.

Children learn to not act out their sexuality in an explicit way and as a result the parents are not aware of all of the children’s behaviours and cannot report them. This can explain why retrospective studies tend to show higher frequencies; college-age individuals can self-report behaviours in childhood that they would never have displayed if a parent had been present. Four percent of female college undergraduate students recalled having oral-genital contact during childhood [22] and in a self-reporting study of child welfare and mental health workers asked to recall sexual behaviours when they were 13 years old or younger, 16 percent recalled simulating intercourse with other children and five percent remember inserting an object into the vagina or rectum of another child [28]. This indicates that it is uncommon for children to show this kind of behaviour in public and when such behaviour is carried out openly it might have its roots (traumatic response) in exposure to events such as sexual abuse [5,29,30]. Further studies are needed to explore the relationship between these unusual behaviours and specific childhood experiences

Third, some gender differences among family habits, general and sexual behaviours were found. Nearly 90% of both girls and boys mostly played with friends of the same sex. Girls tended to have more physical contact (hugs and kisses) with both friends and parents than boys. Girls had a bath or a shower with the parent of the same sex or a sibling more often than boys. Boys seem to be more exhibitionistic than girls, highlighted by the fact that they significantly more often touch genitals at home and in public and also more often explore body and genitals.

A limitation of this study, as of most studies in this area, is that all the data are based on parents’ observations and reporting and not on interviews or by directly observing the children. There is a risk for underreporting as when the child grows older he or she has more integrity and need of privacy and the parents do not know what the child is doing all of the time. There is also a limitation that the parents in our study were more educated compared to parents of children in the same age group generally in Sweden. Research shows that higher parental education is associated with the reporting of more child sexual behaviours [31]. The behaviours the parents report are what they observe and not all of the child’s sexual behaviours. In addition, different observers may have different levels of motivation for giving reports that are accurate and complete [10]. The participating parents could also be more accepting than the parents who decided not to participate in the study. The majority of the parents who answered our questions are mothers so we know less about the views of fathers. The participation rate was 63.1% and must be seen as satisfactory concerning the sensitive topic of the study but we lack information about the children of the parents who chose not to participate in the study or why they decided not to participate.

In summary, most of the parents believed that their child’s sexual behaviour was normal. But we have to keep in mind that what one believes is normal depends on a number of factors such as age, gender, education, culture, religion, awareness and attitudes towards sexuality etc [20]. A behaviour can be classified as normal by the parents but become problematic if the frequency is such that the behaviour becomes disruptive to others [11]. Children in this age group have often started a socialization process and most probably do not show all of their sexual behaviours to adults [4]. When parents or professionals react to a child’s sexual behaviour it could be because the child exhibits an uncommon sexual behaviour. Professionals are often supposed to decide whether a sexual behaviour is “normal” or not and studies indicate an insecurity among this group [13-16]. When a sexual behaviour is a result of the child’s curiosity and desire there are no red flags but when a child shows a sexually obsessive behaviour or behaves in a very sexually explicit way it should draw attention from adults close to the child. The parents of the children in our study reported very little behaviour that could be considered as signals of children being at risk.

Because an abnormal sexual behaviour in a child can be an indicator that the child is at risk [2,7] clinicians must be able to decide what sexual behaviour is normal and healthy and what is not. In this study, we have tried to show the frequency of different sexual behaviours in a sample of normal, younger Swedish school children but more research in the field is needed to provide clinicians with valid evidence to be able to detect children in need of further investigation and perhaps professional care. For further research it would be interesting and useful to compare our results with results of sexually abused children of the same age.

This study was supported by generous grants from the Swedish Council for Working Life and Social Research.