Sexual behaviors in children range from normal and developmentally appropriate to abusive and violent. While earlier studies 1,2 have suggested a strong correlation between sexual abuse and sexual behavior problems in children, more recent studies 3,4 have broadened this perspective, recognizing a number of additional stressors, family characteristics, and environmental factors that are associated with intrusive and frequent sexual behaviors. Clinicians must first distinguish age-appropriate and normal sexual behaviors from behaviors that are developmentally inappropriate and/or abusive (sexual behavior problems). The information below identifies when children’s behaviors are normal, less common and require assessment of situational factors, uncommon and require assessment of situational factors and family characteristics, and rarely normal and therefore indicate a referral to child protective services. This table was adapted from the American Academy of Pediatrics (AAP) clinical report, “Evaluation of Sexual Behaviors in Children” and should not be used in isolation to determine if a child has been sexually abused. For more information on evaluation of child sexual abuse, review the AAP policy statement, “The Evaluation of Sexual Abuse in Children”.
Examples of Sexual Behaviors in Children Aged 2 Through 6 Years
Normal, common behaviors

•Touching/masturbating genitals in public/private
• Viewing/touching peer or new sibling genitals
• Showing genitals to peers
• Standing/sitting too close
• Tries to view peer/adult nudity
• Behaviors are transient, few, and distractible

Less common normal behaviors (a)

• Rubbing body against others
• Trying to insert tongue in mouth while kissing
• Touching peer/adult genitals
• Crude mimic of movements associated with sexual acts
• Sexual behaviors that are occasionally, but persistently, disruptive to others
• Behaviors are transient and moderately responsive to distraction

Uncommon behaviors in normal children (b)

• Asking peer/adult to engage in specific sexual act(s)
• Inserting objects into genitals
• Explicit imitation of intercourse
• Touching animal genitals
• Sexual behaviors that are frequently disruptive to others
• Behaviors are persistent and resistant to parental distraction

Rarely normal (c)

• Any sexual behaviors involving children who are 4 or more years apart
• A variety of sexual behaviors displayed on a daily basis
• Sexual behavior that results in emotional distress or physical pain
• Sexual behaviors associated with other physically aggressive behavior
• Sexual behaviors that involve coercion
• Behaviors are persistent and child becomes angry if distracted
(a) Assessment of situational factors (eg, family nudity, day care, new sibling) contributing to behavior recommended (b) Assessment of situational factors, family characteristics (eg, violence, abuse, neglect) recommended (c) Assessment of all family and environmental factors and report to child protective services recommended.

References
1. Gale J, Thompson RJ, Moran T, Sack WH. Sexual abuse in young children: its clinical presentation and characteristic patterns. Child Abuse Negl. 1988;12:163–170
2. Friedrich WN. The clinical use of the child sexual behavior inventory: frequently asked questions. APSAC Advisor.1995;8:1–20
3. Friedrich WN, Fisher JL, Dittner CA, et al. Child sexual behavior inventory: normative, psychiatric, and sexual abuse comparisons. Child Maltreat. 2001;6:37–49
4. Silovsky JF, Niec L. Characteristics of young children with sexual behavior problems: a pilot study. Child Maltreat. 2002;7:187–197