Normative Sexual Behavior in Children: A Contemporary Sample

William N. Friedrich, PhD*; Jennifer Fisher, PhD*; Daniel Broughton, MD*; Margaret Houston, MD*; and
Constance R. Shafran, PhD‡

ABSTRACT. Objective. Sexual behavior in children most people. Young children, who are just learning
can cause uncertainty in the clinician because of the the culturally appropriate distance, may stand too
relationship between sexual abuse and sexual behavior. close, rub against people, or casually touch their
Consequently, it is important to understand normative mother’s breasts or father’s genitals.
childhood sexual behavior. Exhibitionistic behavior in children, deliberately
Design. Sexual behavior in 1114 2- to 12-year-old chil-
dren was rated by primary female caregivers. These chil-
exposing body parts to other children or adults, may
dren were screened for the absence of sexual abuse. A also take the form of “playing doctor.” Gender role
38-item scale assessing a broad range of sexual behavior behavior reflects the sex-typing of interests and be-
(Child Sexual Behavior Inventory, Third Version) was haviors seen in children,3 and self-stimulation sub-
administered along with the Child Behavior Checklist sumes masturbation as well as touching or rubbing
and a questionnaire assessing family stress, family sex- different parts of the body to bring pleasure.
uality, social maturity of the child, maternal attitudes Children may show excessive modesty or anxiety
regarding child sexuality, and hours in day care. at displays of affection between parents or other
Results. Sexual behavior was related to the child’s individuals. Alternatively, children may be very cu-
age, maternal education, family sexuality, family stress,
rious and open regarding sexual matters, including
family violence, and hours/week in day care. Frequencies
of sexual behaviors for 2- to 5-, 6- to 9-, and 10- to 12- interest in the opposite sex and interest in more
year-old boys and girls are presented. mature television shows or videos.
Conclusions. A broad range of sexual behaviors are Sexual intrusiveness has captured considerable
exhibited by children who there is no reason to believe concern of late, particularly with our increasing
have been sexually abused. Their relative frequency is awareness that preteens can behave in sexually co-
similar to two earlier studies, and this reinforces the ercive ways with other children.4 More normative
validity of these results. Pediatrics 1998;101(4). URL: manifestations of this behavioral domain could in-
http://www.pediatrics.org/cgi/content/full/101/4/e9; sex- clude the mutual touching of another child’s sex
ual behavior, children, family sexuality parts. Sexual knowledge is a child’s basic under-
standing of sexual acts. It has been shown to vary
ABBREVIATIONS. CSBI, Child Sexual Behavior Inventory; CBCL, with the child’s age and the education level of the
Child Behavior Checklist. parents.5 Voyeuristic behavior, probably a variant of
sexual interest, might be reflected in children at-
tempting to catch glimpses of nude or partially

S
exual behavior in children has been the focus of
increasing attention over the past decade, after dressed children and adults.
the advent of research that demonstrated a con- The parental report has been the most widely used
sistent relationship between sexual abuse and sexual method to assess sexual behavior in children. For
behavior in children.1 Although a broad range of example, parents reported that 30% to 45% of chil-
sexual behaviors has been observed in normal chil- dren under 10 years of age touched their mother’s
dren,2 further research is needed to expand the breasts or genitals at least once.6 Parents have also
knowledge base of practicing pediatricians regarding reported that sex typing increases during the pre-
what is normative about sexual behavior in children. school years with older children increasingly adopt-
Sexual behavior in children can be sorted into a ing gender roles.3 On the Child Sexual Behavior In-
number of categories, all of them having an adult ventory (CSBI), a parental report measure, sexual
behavioral correspondence. These include adherence behaviors were typically reported more often by par-
to personal boundaries, exhibitionism, gender role ents of sexually abused children. However, all of the
behavior, self-stimulation, sexual anxiety, sexual in- sexual behaviors studied were endorsed by parents
terest, sexual intrusiveness, sexual knowledge, and for at least some children for whom there was no
voyeuristic behavior.2 Personal boundaries reflect parental suspicion of sexual abuse.7,8
the presumed interpersonal distance maintained by Day care providers have been used as reporters in
several studies. A sample of 564 day care providers
was asked about the sexual behavior of 1- to 3- and
From the *Mayo Clinic, Rochester, Minnesota. 4- to 6-year-old children.9 The most consistent find-
‡Private practice, Malibu, California. ing was age-related, with the youngest group, for
Received for publication Jul 14, 1997; accepted Dec 12, 1997.
Reprint requests to (W.N.F.) West 11B, Mayo Clinic, Rochester, MN 55905.
example, judged to be the most comfortable with
PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad- their own nudity. Day care providers reported that a
emy of Pediatrics. majority of 4- to 6-year-olds interacted spontane-

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2020101 No. 4 April 1998 1 of 8
ously, at least occasionally, in sexual ways. Children cluding sexual behavior. This was reiterated in the consent form
in this age range were also reported to have imitated they were asked to read and sign. In addition, they were asked
two separate questions in the CSBI materials about suspected or
sexual behaviors that they had seen demonstrated or substantiated sexual abuse. More specifically, they were asked to
had heard about. Swedish day care providers re- answer yes or no regarding any reason to suspect sexual abuse or
ported relatively low frequencies of intrusive and whether sexual abuse had ever been substantiated, and, if so, at
self-stimulating behaviors, a finding similar to re- what age. Finally, a total of 34 mothers in the Minnesota sample
were then interviewed briefly over the phone to clarify their
search with the CSBI.10 endorsement of a behavior reported on the CSBI. Typically, these
Retrospective self-reports have also been used to mothers had reported at least one unusual behavior. Each of these
understand normal sexual behavior. Lamb and mothers were asked again if they had any reason to believe their
Coakley11 interviewed female undergraduates about child had been sexually abused, and in no case did they report
their recollection of having participated in sexual anything different from their earlier statements. Taken together,
this supports the screening process used. However, it is likely that
play as a child (mean age 5 7.5 years, standard some children with a history of sexual abuse were included in the
deviation 5 2.0). Of particular relevance to research normative sample.
with the CSBI is the fact that 14% reported kissing A total of 1003 parents were approached and 945 agreed to
another child, 26% reported exposing themselves, participate. This represents a 94.2% participation rate. Of this
number, 46 were excluded because of recent counseling, 11 be-
15% reported genital touching while clothed, 17% cause of mental retardation, and 6 because of a physical handicap.
reported unclothed genital touching, 6% reported A total of 32 (3.4%) were excluded because of actual or suspected
using objects in or around genitals, and 4% reported sexual abuse. Finally, only CSBI forms that were fully completed
oral-genital contact. (For some of the above behav- were used, and 51 were removed. (Some subjects were excluded
iors, parents reported an even higher frequency on for more than one reason.) A total of 834 children were retained.
the CSBI, ie, 38.4% of parents reported their child
had touched their genitals in the previous 6 months. Los Angeles County Samples
This would suggest that for some behaviors, parents These samples consisted of 280 3- to 6-year-old children re-
may be more valid reporters, particularly if rating cruited from public and private day care programs in Los Angeles
behaviors contemporaneously.)2 The more often the County. Day care administrators granted permission to the inves-
tigator (C.R.S.) to recruit volunteers who agreed to participate in a
sexual games involved a cross-gender experience, study of children’s behavior, including sexual behavior. Mothers
the more likely the game was perceived as manipu- then completed the CSBI in small groups or individually. Thirteen
lative or coercive. sibling pairs were included in this sample, with all the rest being
Given the need to understand normative sexual the only child from their family that was rated. The parents were
compensated for their participation.
behavior in children as well as its relation to life A total of 19% (N 5 53) of the children initially rated were
circumstances other than sexual abuse, the CSBI was excluded for various reasons. These included 11 children because
modified to be both more readable and contain items of suspected or substantiated sexual abuse, 16 because of incom-
that were as specific as possible. Readability has been plete responses, 13 because of age, 9 because of a mental or
calculated at the 5th grade using Grammatik. The physical handicap, and another 4 for other reasons. The investi-
gator was personally present and available to answer the ques-
third version of the CSBI used in this study also tions of the mothers in the study, and this allowed further screen-
reflected research with two previous versions. Fi- ing out of sexually abused children.
nally a larger, more ethnically diverse sample of 2- to Because there were no mean differences on item endorsement
12-year-old children was obtained. These were chil- for the two samples, they were combined. The total sample of 1114
well represents gender (49.7% female) and race (77.7% white, 7.7%
dren for whom parents reported no reason to believe black, and 11.6% Hispanic). The income and racial composition of
they had been sexually abused. In addition, family this sample reflect more diversity than the two earlier normative
and child variables were gathered simultaneously samples,2,8 with more lower income subjects as well as more
and their relationship to sexual behaviors was subjects who are black or Hispanic. Specific demographics of the
studied. combined normative sample are presented in Table 1.

METHODS Questionnaire
Samples The 9-page questionnaire had three sections: a demographic
data sheet, the 38-item CSBI, and the Problem Behavior portion of
Subjects were recruited in two sites in Minnesota as well as
the Child Behavior Checklist (CBCL).12 The demographic portion
several sites in California. Each will be described in turn.
obtained information on age and gender of the child; marital,
financial, and educational status of the parents; family size; peer
Minnesota Samples relationships of the rated child; hours/week in day care; a life
Subjects were recruited from families who used either a pri- events checklist; and a family sexuality checklist, (eg, co-sleeping,
mary care pediatric clinic (N 5 723) or a family medicine clinic co-bathing, liberal television/video standards, witnessing inter-
(N 5 111) in a large, multispeciality clinic that serves the primary course, availability of pornography, and an item asking about
care needs of a small midwestern city and the immediately sur- parental attitudes regarding the normalcy of sexual behavior in
rounding area. To be eligible for the study, a family had to have at children). Two separate questions in the life events checklist
least 1 child between 2 and 12 years of age. Only mothers were screened for suspected or verified sexual abuse. The remaining life
used as reporters. Mothers were recruited in the waiting rooms of events items obtained information on whether the child had ever
the respective clinics by a trained female research assistant who experienced the following: parental battering, parental death, pa-
recruited consecutive parents into the study. Natural mothers rental arrest, other family deaths, parental illness requiring hos-
accounted for 98.1% of the mothers, with the remainder being pitalization, and child illness requiring hospitalization.
adoptive or stepmothers. Only 1 child in the 2- to 12-year age The CSBI asks for the frequency of behaviors during the past 6
range was recruited per family, with the child typically being the months and is scored as 0, 1, 2, or 3 to reflect levels of frequency,
one present at the clinic that day. ie, 0 5 never; 1 5 less than once/month; 2 5 1 to 3/month; and
It was important in the development of the normative sample 3 5 at least 1/week. The 38-item version of the CSBI used in this
to exclude children with a suspicion or substantiated history of study was based on the 36-item version studied earlier.8 Of the 36
sexual abuse. Each mother was verbally informed that they were items, 22 remained identical, 1 was dropped, 3 were added, and 12
being asked to participate in a study of children’s behavior, in- were rewritten to read more simply and clearly, eg, Item number

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TABLE 1. Demographic Data
Percent female 49.7
Child’s age, mean y (SD) 5.98 (2.89)
Maternal education, mean y (SD) 14.37 (2.62)
Paternal education, mean y (SD) 15.00 (3.72)
Race
White 77.7
Black 7.7
Hispanic 11.6
Asian 1.7
Native American .5
Other .7
Family income
,10 000 8.9
10 000–15 000 7.6
15 000–25 000 7.6
25 000–35 000 11.5
Fig 1. Plot of CSBI item mean scores across ages for both genders.
35 000–45 000 13.7
45 000–60 000 17.2
60 000–80 000 14.9
.80 000 18.6 children are observed to be relatively sexual (com-
Marital status pared with 10- to 12-year-olds) and children become
Single 8.9
Married 76.3 increasingly sexual up to age 5, when the item mean
Separated 3.1 drops for both genders. Another drop occurs after
Divorced 10.9 age 9, although 11-year-old girls show a slight rise in
Widowed .9 sexual behavior, primarily coming from an increased
Total n 5 1114
interest in the opposite sex, ie, Item number 35, “Is
very interested in the opposite sex.” At age 12, boys
also show a similar slight rise in mean score, again
19 changed from “inserts or tries to insert objects in vagina/anus”
to “puts objects in vagina or rectum.” primarily attributable to an increase in endorsement
The CBCL12 is a widely used screening measure of children’s of the same item. Finally, the correlation of the CSBI
behavior. Two versions were used, the 99-item version for 2- to total score with age was also significant, r 5 -.27, P ,
3-year olds and the 113-item version for 4- to 18-year-olds. A .0001, suggesting even further the need to consider
3-point scale is used, ie, never, sometimes, often, and the child is
rated over the previous 6 months. The CBCL assesses internalizing
age in the calculation of frequencies.
(eg, depression, anxiety, withdrawal) and externalizing behaviors Because of these developmental trends, further
(eg, aggression, delinquency, hyperactivity). analyses examined three groups of children instead
of the two used in earlier research.2,8 These three age
RESULTS groups are 2- to 5-year-olds, 6- to 9-year-olds, and 10-
Our findings will be presented in the following to 12-year-olds. (The age and sex distribution of the
order: 1) the developmental course of observed sex- sample are presented in Table 2.)
ual behavior in 2- to 12-year-olds; 2) the relative
frequency of sexual behaviors in this normative sam- Relative Frequency
ple; 3) the internal reliability of the CSBI; 4) the To determine the frequencies of the various sexual
relationship of sexual behaviors to family variables; behaviors, the proportion of children endorsing each
and 5) the relationship of sexual behaviors to general item on the CSBI was computed across the three age
behavior problems. and gender groups. See Tables 3 and 4 for these
results.
Developmental Course Endorsement was defined as a score of either 1, 2,
We hypothesized that sexual behavior in children or 3, meaning the child had exhibited the behavior at
will vary by the age of the child, in part because least once in the preceding 6-month period. Thus, the
reported sexual behavior will reflect the parent’s frequencies reported in Table 3 are simply the per-
ability to observe their child. Developmental transi- centage of parents who reported the presence of the
tions in sexual behavior are thus a function of child’s behavior.
age and observability. To determine change in fre- A review of the reported endorsement frequencies
quency over time, the item mean was calculated for indicated that for each age and gender group, there
all 38 items and plotted across each year of age for are 1 to 5 items that at least 20% of the parents
both boys and girls. These results are illustrated in endorsed. The 20% criterion was chosen because if
Fig 1. one considers a normal distribution, the upper 20%
An examination of Fig 1 suggests that 2-year-old of the sample (80% and above) is not as extreme as 1

TABLE 2. Age and Sex Distribution of Normative Sample

Age (y) Total
2 3 4 5 6 7 8 9 10 11 12
Male 40 93 92 62 58 39 43 51 31 29 22 560
Female 41 96 83 67 60 32 41 38 40 34 22 554
Total 81 189 175 129 118 71 84 89 71 63 44 1114

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TABLE 3. Simple Endorsement Frequencies of Sexual Behaviors for the Three Male Age Groups
Item No. (Abbreviated) 2–5 Years Old 6–9 Years Old 10–12 Years Old
N 5 287 N 5 191 N 5 82
1. Dresses like opposite sex 13.8 5.9 0.0
2. Stands too close 29.3 14.4 7.5
3. Wants to be opposite sex 6.0 4.3 1.2
4. Touches sex parts in public 26.5 13.8 1.2
5. Masturbates with hand 16.7 12.8 3.7
6. Draws sex parts 1.4 2.7 1.2
7. Touches breasts 42.4 14.3 1.2
8. Masturbates with toy/object 3.5 2.7 1.2
9. Touches other child’s sex parts 4.6 8.0 1.2
10. Tries to have intercourse 0.4 0.0 0.0
11. Puts mouth on sex parts 0.7 0.0 0.0
12. Touches sex parts at home 60.2 39.8 8.7
13. Touches adult’s sex parts 7.8 1.6 0.0
14. Touches animal’s sex parts 2.8 0.5 0.0
15. Makes sexual sounds 0.7 1.1 1.2
16. Asks others to do sex acts 0.4 0.5 0.0
17. Rubs body against people 7.1 5.3 0.0
18. Puts objects in vagina/rectum 0.4 0.0 0.0
19. Tries to look at people when they are nude 26.8 20.2 6.3
20. Pretends toys are having sex 0.7 1.6 0.0
21. Shows sex parts to adults 15.4 6.4 2.5
22. Tries to look at pictures of nude people 5.4 10.1 11.4
23. Talks about sex acts 2.1 8.5 8.9
24. Kisses adults not known well 7.5 1.1 0.0
25. Gets upset when adults kiss 13.2 6.4 3.8
26. Overly friendly with men 2.5 1.1 0.0
27. Kisses other children 7.9 1.1 0.0
28. Talks flirtatiously 3.2 3.7 3.8
29. Undresses other children 1.4 1.1 0.0
30. Wants to watch TV nudity 5.0 8.0 15.2
31. Puts tongue in mouth when kissing 4.3 1.1 1.3
32. Hugs adults not known well 15.4 3.7 0.0
33. Shows sex parts to children 9.3 4.8 0.0
34. Undresses adults against their will 4.3 0.5 0.0
35. Very interested in opposite sex 17.5 13.8 24.1
36. Puts mouth on breasts 5.7 0.5 0.0
37. Knows more about sex 5.3 13.3 11.4
38. Other sexual behaviors 4.3 3.6 1.3
Mean total score (SD) 5.0 (4.5) 3.3 (4.2) 1.5 (2.2)

standard deviation above the mean (84.13% and the entire sample.13 All of the items were positively
above), and can therefore be considered more nor- correlated with the total score, with a resulting a
mative. These items can be considered as develop- coefficient of .72. It is likely that a sample with more
mentally-related sexual behaviors, meaning that they variance, ie, a clinical sample, would have a higher a
were observed in a significant percentage of children on this scale.
for that age and gender group. In addition, there are
very few gender differences for each age group sug- Influence of Family and Cultural Variables
gesting as well that these are age-related. See Table 5 The relations of several demographic variables to
for a listing of these items across the age groups. the Mean Child Sexual Behavior Score were calcu-
Items pertaining to sexually intrusive, eg, “touches lated with multiple regression. The entire normative
or tries to touch their mother’s or other women’s sample was used. Four variables were entered as a
breasts,” or self-stimulating eg, “touches sex (pri- block, ie, family income, gender, age in years, and
vate) parts when at home,” behaviors seen in the mother’s years of education. Age (F 5 9.3,
younger children, drop off in observed frequency R2 5.06, P , .00001) and maternal education (F 5 5.0,
with age. R2 5.038, P , .00001) were significantly related to
Some of the sexual behaviors are extremely un- sexual behavior and together accounted for approx-
common at all age and gender groups. However, imately 10% of the explained variance. However,
consistent with earlier research with this measure, neither gender nor family income were significantly
every item was endorsed by at least a few parents in related after the variance contributed by age and
this larger and more ethnically and economically maternal education was considered. This finding in-
diverse sample. dicated that younger children had significantly
higher CSBI scores than older children, and mothers
Reliability of the CSBI with more years of education reported more sexual
To assess the interrelationships among the items, behavior than less educated mothers.
and to determine if the items can be added to calcu- The relations of several child and family variables
late a total score, an a coefficient was calculated for to the total CSBI score were then examined in the

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TABLE 4. Simple Endorsement Frequencies of Sexual Behaviors for the Three Female Age Groups
Item No. (Abbreviated) 2–5 Years Old 6–9 Years Old 10–12 Years Old
N 5 287 N 5 171 N 5 96
1. Dresses like opposite sex 10.2 8.8 8.4
2. Stands too close 25.8 18.8 14.8
3. Wants to be opposite sex 8.5 3.5 4.2
4. Touches sex parts in public 15.1 6.5 2.2
5. Masturbates with hand 15.8 5.3 7.4
6. Draws sex parts 3.2 2.4 2.1
7. Touches breasts 43.7 15.9 1.1
8. Masturbates with toy/object 6.0 2.9 4.3
9. Touches other child’s sex parts 8.8 1.2 1.1
10. Tries to have intercourse 1.1 0.0 0.0
11. Puts mouth on sex parts 0.0 0.0 0.0
12. Touches sex parts at home 43.8 20.7 11.6
13. Touches adult’s sex parts 4.2 1.2 0.0
14. Touches animal’s sex parts 2.5 0.6 0.0
15. Makes sexual sounds 2.8 1.8 0.0
16. Asks others to do sex acts 0.4 0.0 0.0
17. Rubs body against people 3.2 3.6 2.2
18. Puts objects in vagina/rectum 2.8 0.0 0.0
19. Tries to look at people when they are nude 26.9 20.5 5.3
20. Pretends toys are having sex 1.1 3.6 3.2
21. Shows sex parts to adults 13.8 5.4 2.2
22. Tries to look at pictures of nude people 3.9 10.2 3.2
23. Talks about sex acts 3.2 7.2 8.5
24. Kisses adults not known well 6.0 2.4 1.1
25. Gets upset when adults kiss 12.1 7.2 5.4
26. Overly friendly with men 6.4 1.2 1.1
27. Kisses other children 7.1 1.2 1.1
28. Talks flirtatiously 7.1 6.0 5.3
29. Undresses other children 2.1 0.0 0.0
30. Wants to watch TV nudity 6.4 8.4 12.8
31. Puts tongue in mouth when kissing 1.8 3.0 0.0
32. Hugs adults not known well 12.8 6.6 4.3
33. Shows sex parts to children 6.4 2.4 1.1
34. Undresses adults against their will 2.1 1.2 0.0
35. Very interested in opposite sex 15.2 13.9 28.7
36. Puts mouth on breasts 4.3 2.4 0.0
37. Knows more about sex 5.3 15.5 17.9
38. Other sexual behaviors 3.1 2.7 0.0
Mean total score (SD) 4.7 (4.8) 2.7 (3.5) 2.2 (3.5)

normative sample. Child variables included the qual- tation in such externalizing behaviors as aggression
ity of peer relationships, ethnic status (white, non- as well as sexual behavior.14 Family violence also
white), and hours/week in day care. Family vari- reflects a problem with personal boundaries, one of
ables included marital status (single, not single), life the sexual behavior categories measured by the CSBI.
stress, family violence (the presence of physical It seems that total number of hours in day care/
abuse and/or parental battering), the total number of week contributes a clinically significant increase in
children in the family, and family sexuality. reported child sexual behavior in children with no
The block of demographic variables described known history of sexual abuse. Why that is the case
above, ie, income, age of child, gender, and maternal is difficult to determine without more information.
education was first entered. At the next step in the Although age was a covariant in the regression anal-
multiple regression analysis, one of the child or fam- ysis, younger children typically spend more hours/
ily variables was added. In this manner, the unique week in day care, and the younger children in the
variance accounted for by that individual variable normative sample were more overtly sexual.
could be determined. The significant relationship of life stress and sexual
Of the eight additional variables assessed, four behavior is intriguing also. Life stress in children has
were significant at the P , .05 level or better. These been implicated in many psychosocial and behav-
were family violence (F 5 2.1, R2 5 .006, P , .03), ioral problems.15 Presumably, the relationship holds
hours/week in day care (F 5 3.8, R2 5 .01, P , .0001), for sexual behavior also.
life stress (F 5 2.8, R2 5 .007, P , .005), and family Parents who reported a more relaxed approach to
sexuality (F 5 9.9, R2 5 .057, P , .00001). Unique co-sleeping, co-bathing, family nudity, opportunities
variance, reflected in change in R2, was ,1% for to look at adult movies/magazines, and witness in-
family violence and life stress, 1.0% for hours/week tercourse, also reported higher levels of sexual be-
in day care, and 5.7% for family sexuality. havior in their 2- to 12-year-old child, even after
The relationship of family violence to sexual be- controlling for the effects of several other family
havior in children may reflect the dysregulating ef- variables.
fect of family violence, and its subsequent manifes- Finally, parents in the contemporary normative

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TABLE 5. Developmentally Related Sexual Behaviors
Question No. Item % Endorsement
2- to 5-year-old boys
2 Stands too close to people 29.3
4 Touches sex (private) parts when in public places 26.5
7 Touches or tries to touch their mother’s or other women’s breasts 42.4
12 Touches sex (private) parts when at home 60.2
19 Tries to look at people when they are nude or undressing 26.8
2- to 5-year-old girls
2 Stands too close to people 25.8
7 Touches or tries to touch their mother’s or other women’s breasts 43.7
12 Touches sex (private) parts when at home 43.8
19 Tries to look at people when they are nude or undressing 26.9
6- to 9-year-old boys
12 Touches sex (private) parts when at home 39.8
19 Tries to look at people when they are nude or undressing 20.2
6- to 9-year-old girls
12 Touches sex (private) parts when at home 20.7
19 Tries to look at people when they are nude or undressing 20.5
10- to 12-year-old boys
35 Is very interested in the opposite sex 24.1
10- to 12-year-old girls
35 Is very interested in the opposite sex 28.7

sample were also asked whether they agreed with DISCUSSION

the item, “It is normal for children to have sexual The frequencies of a broad range of sexual behav-
feelings and curiosity?” Using the multiple regres- iors in 2- to 12-year-old children were rated by their
sion procedure described above, ie, controlling for mothers. The results were extremely consistent with
the effects of age, gender, family income, and mater- earlier research, and clearly indicate that children
nal education, the relationship of this question to exhibit numerous sexual behaviors at varying levels
CSBI mean was significant, F 5 2.2, R2 5 .015, P , of frequency.2,8 Sexual behaviors that appear to be
.03, and this question accounted for 1.5% of unique the most frequent include self-stimulating behaviors,
variance. exhibitionism, and behaviors related to personal
Based on the demographic analyses reported here, boundaries. Less frequent behaviors are clearly the
as well as gender-different patterns in the endorse- more intrusive behaviors.
ment of certain items, both age and gender were Sexual behavior showed an inverse relationship
judged to be important variables upon which to stan- with age, with overall frequency peaking at year 5
dardize the CSBI. Norms based on racial groups for both boys and girls, and then dropping off over
were not derived given the insignificant contribution
the next 7 years. This is reflected in the relatively
of race after the influence of maternal education and
large number of behaviors endorsed by at least 20%
family income were considered. The lack of ethnic
of caregivers for the 2- to 5-year-old group. One
differences also supports the combination of Minne-
could consider these behaviors to be developmen-
sota and California samples.
tally related and within normal limits.
Sexual Behavior and Other Behavior Problems It is important to remember that children’s behav-
Both internalizing and externalizing T scores from ior must be interpreted in light of individual and
the CBCL were significantly related to the total sex- family variables. The same is true for sexual behav-
ual behavior score on the CSBI, even when first ior. For example, in addition to the significant in-
removing the contribution of age, gender, family verse relationship with age, sexual behavior ap-
income, and maternal education, ie, F 5 5.5, R2 5 .14, peared to be directly and significantly related to
P , .0001, and F 5 7.8, R2 5 .18, P , .0001, respec- maternal education as well as a maternal attitude
tively. about the normalcy of sexual behavior in children.
Mothers with more years of education and who re-
Comparability to Earlier Versions ported their belief that sexual feelings and behavior
Table 6 presents the simple endorsement frequen- in children was normal, reported more sexual behav-
cies of the identical and similar items that were ior. This observed relationship of reported sexual
shared across at least two of the three versions of the behavior to education and social class has been re-
CSBI. Because the mean ages of each of the sample ported earlier.16
differed slightly, analysis of covariance was used to Reasons for this could include more liberal atti-
examine sample differences across each item while tudes toward sexuality in better educated families,
covarying out the effects of age. There were no sig- which may be related to a greater comfort in report-
nificant (P , .05) differences on any item, further ing the pressence of sexual behaviors in their child.
supporting the reliability of these behavior ratings. Better educated parents may also be in a position to
In addition, a simple review of endorsement fre- be more observant of their children, thus witnessing
quencies notes that only 24 out of 92 possible two- behaviors that less observant, or more preoccupied
group comparisons differed by .5%. parents might miss.

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TABLE 6. Rank-Order of Endorsement Frequencies for Shared Items of Three CSBI Versionsa
Item No. (Abbreviated)b CSBI-1c (N 5 880) CSBI-Rd (N 5 141) CSBI-3e (N 5 1114)
11 Puts mouth on sex parts .1 1.4 .2
16 Asks others to engage in sex acts .4 0.0 .3
8 Masturbates with object .8 2.8 3.9
18 Inserts objects in vagina/rectum .9 2.8 .8
10 Imitates intercourse 1.1 0.0 —
15 Sexual sounds 1.4 0.0 1.4
31 French kisses 2.5 0.0 2.3
29 Undresses other people 2.6 1.4 1.2
30 Asks to watch explicit TV 2.7 1.4 7.7
20 Imitates sex behavior with dolls 3.2 1.4 1.6
3 Wants to be opposite sex 4.9 2.8 5.4
23 Talks about sexual acts 4.7 2.8 5.3
1 Dresses like the opposite sex 5.8 7.0 9.3
9 Touches others’ sex parts 6.0 9.8 —
17 Rubs body against people 6.7 9.8 4.3
32 Hugs strange adults 7.3 12.7 9.5
33 Shows sex parts to children 8.1 11.3 5.3
13 Uses sexual words 8.8 2.8 —
34 Overly aggressive, overly passive 10.4 2.8 —
28 Talks flirtatiously 10.6 1.4 4.9
5 Masturbates with hand 15.3 19.6 12.4
22 Looks at nude pictures 15.5 9.9 6.7
21 Shows sex parts to adults 16.0 4.2 9.8
4 Touches sex parts in public 19.7 28.8 14.4
35 Interested in the opposite sex 23.0 9.9 17.1
19 Tries to look at people undressing 28.5 23.9 21.4
7 Touches breasts 30.7 35.3 27.3
27 Kisses children they don’t know well — 8.5 4.5
24 Kisses adults they don’t know well — 7.0 4.3
6 Draws sex parts — 2.8 2.3
14 Touches animals’ sexual parts 1.3 2.8 1.5
25 Gets upset by public displays of affection — 9.8 9.6
26 Overly friendly with men they don’t know well 7.1 2.8 2.8
36 Mouth on breasts 2.6 0.0 3.0
2 Stands too close to people 11.6 18.3 21.3
12 Touches sex parts at home 45.8 39.5 38.4
a
Only identical or similar items are included. The current version includes some new items.
b
The entire items is not reprinted. The item number reflects the number of the item for the current version.
c
Friedrich et al.7
d
Friedrich.8
e
Current version.

The lack of significance noted for ethnicity war- is nothing in this data that indicates that parents
rants some discussion. A purpose of this study was should alter their family sexuality practices. Rather,
to deliberately assess a more ethnically and socioeco- the data affirm the premise that the behavior of
nomically diverse sample than previous research on children is reflective of the context in which they are
childhood sexuality. The fact that .22% of the sam- raised.
ple was a member of an ethnic minority should have It is less clear how hours in day care are related to
been sufficient to identify any differences that were sexual behavior in children. However, children in
present. Ethnic status did correlate significantly with day care are likely to be exposed to children who
family income in this sample (r 5 .45, P , .0001), and have been raised by parents whose attitudes toward
it may be that any unique variance ethnic status may child-rearing may be quite different than their own
have added was eliminated by entering family in- parents. Peer socialization around sexuality is as
come in the first block of variables in the multiple likely as other processes that are mediated by peers.
regression analysis. Future research is needed to ex- The relationship of children’s sexuality to hours in
amine this question more precisely. day care may reflect more chances to interact with
The direct relationship of reported family sexuality children who vary regarding sexuality.
with sexual behavior was also noted in this study. Sexual behavior was also significantly related to
This finding validates earlier research with the first both family violence and total life stress, even after
version of the CSBI.2 There are likely two pathways controlling for the effects of maternal education and
to this relationship. The more direct pathway is that family income. Both of these have been shown to be
a more relaxed family attitude regarding nudity or related to behavior problems in children,15 and to the
observing adult sexuality results in children in that extent that sexual behavior can be problematic, it is
family being more likely to exhibit sexuality. It may likely that a similar connection exists. Life stress may
also be that a greater openness and honesty about reflect less consistent parenting and as a result may
one’s own sexuality is related to more disclosure predispose a child to act out in a variety of ways.
about one’s child’s sexual behavior. However, there Family violence is a model for boundary problems

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and intrusive behavior. Although not examined di- abused. Rather, it is a behavior that is seen in almost
rectly in this study, family violence may also expose two thirds of boys at that age. This same pediatrician
a child to adult sexuality in a manner not seen by a may also be in a position to point out when a behav-
child growing up in a more protected environment. ior or group of behaviors is very unusual, raises
Sexual behavior was directly related to other par- concern, and should be addressed.
ent-reported behavior problems. This has been re-
ported in earlier research,2,17 and most likely is a REFERENCES
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 Normative Sexual Behavior in Children: A Contemporary Sample
William N. Friedrich, Jennifer Fisher, Daniel Broughton, Margaret Houston and
Constance R. Shafran
Pediatrics 1998;101;e9
DOI: 10.1542/peds.101.4.e9

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 Normative Sexual Behavior in Children: A Contemporary Sample
William N. Friedrich, Jennifer Fisher, Daniel Broughton, Margaret Houston and
Constance R. Shafran
Pediatrics 1998;101;e9
DOI: 10.1542/peds.101.4.e9

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/101/4/e9

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