Professor Gill Wakley provides health visitors, school nurses and other community nurses with a framework for advising parents how to talk to their children, at various ages, about sex
Health visitors, school nurses and other community nurses are sometimes asked for advice by parents and carers on the emerging sexuality of their children. Parents often lack knowledge about sexual development and are confused about whether to talk to their children about sex. They may have been brought up in a family where sex was not mentioned. They are worried that they do not have the skills or the knowledge to help their children. They do not know whether to leave it all to the school or not allow their children to have any information. All the evidence shows that children who have had their questions answered and who know about sex and relationships start sexual activity later, use contraception more reliably and are less likely to cause or have an unwanted pregnancy.
Sex education should be part of the ordinary information and moral guidance that parents normally give and should start as early as possible. The type of advice to give to parents and carers is split into age ranges that they might find helpful. Examples of language and the level of information required are given. A list of resources for further guidance is included.
_ Parents are often confused about how and when to talk about sex with their children
_ Health visitors, school nurses and other community nurses can give advice on how to cope with this difficult area of parenting
_ Attitudes to sexuality are absorbed from parents
_ Poor sex education can damage children's ability to wait until they are ready for sexual activity
_ Poor sex education can limit the adolescent's ability to use contraception when required
_ Sex education should be geared to the age, emotional maturity and understanding of the child or adolescent
Health visitors, school nurses and other community nurses often find themselves advising parents and carers on children's sexual development. Even if parents want to talk to their children about topics related to sexual behaviours, they often feel embarrassed or think that they do not have the skills or the knowledge to do so. A need for sex and relationship education (SRE) by parents has been identified to ensure that the information taught at school can be reinforced in the family home1. Parents are confused about how to talk to their children about sex and they worry about when to do it, if at all. The sections that follow give some guidance about what advice to give.
What you might tell parents
If individuals have been brought up in a family where sex is not mentioned, they may not know how or when to start with their own children. They may tell their children to be quiet, or say that they will talk to them later and then avoid it, or even angrily shut them up. They may not want them to have sex education at school either; their own fears and attitudes about health get in the way of that safety net. The children will then learn misleading information from ill informed friends.
Children who have had their questions answered correctly and who know about sex and relationships start sexual activity later, use contraception more reliably and are less likely to cause or have an unwanted pregnancy2-4. They learn how to talk about sex sensibly and can negotiate relationships better5,6.
When to start?
As soon as possible! Talking about sex, relationships and those "private parts" should be as natural as talking about what colour the brick is, what the nose is called, and that Dad and Mum love you. Parents can use everyday situations to talk about it. If they don't know, or are unsure of the answer to something, they can say that they will find out.
Three year olds and under
As children start to talk, parents play games with them by pointing to the parts of the body. They should include the nipples, penis, vulva, vagina, anus and urethra. Bath time is a good time to do this. Parents can use the words they are most comfortable with, but it helps if they know (or learn) the technical names for them and use them as well once the child is older. They might say: "We call this your willie, some people call it a penis, or other names." This is just the same as the child learning that what they know as the bathroom is also called a toilet, or lavatory or loo. Once children are out of nappies is probably a good time to introduce the idea of some part of the body being private that not everyone wants to see. Children should know that some people find it embarrassing to be shown a bottom or a penis, however beautiful it is. But parents should hide any embarrassment themselves; that's the best stimulus to showing off!
At this age, pulling on the penis or fingering the vulva is a normal part of self-exploration of the body. Any stimulation of the sexual organs gives pleasurable feedback which is automatic - the penis may become erect, or a girl may rock backwards and forwards to increase the sensation. Parents might want to remind them that this is a private activity (if they are old enough to understand), or distract them (if they are not). If it happens a lot, it can be a sign of lack of other stimulation, or of anxiety, so parents should look for reasons rather than just reacting against it.
Parents can field any questions in a matter-of-fact way, with a short answer. If the question is one that they would rather not answer in public, they should have a ready answer, e.g. "That's a good question. It would take too long to explain now, so remind me when we get home." But they should remember to answer it then!
Threes to fives
Curiosity about other people increases as children become more aware of being different from others. This is the peak age of looking in pants, inspecting other people's bodies in the bath, playing at being doctors and nurses or mummies and daddies. This activity is not sexual - if it comes across as this, a parent might want to know more about where they got the ideas from. Sometimes it can get a bit too enthusiastic too, so parents should be prepared to use distraction or suggest other games. This is often a good age for reminders on how to look after these areas of the body. Parents should take advantage of everyday opportunities to discuss sex. If they see someone who is obviously pregnant, for example, they can explain that the baby is growing in a special place inside the mother. If children want more details on how the baby got there or how the baby will be born, short answers are best. Box 1 gives some examples.
Fives to sevens
Questions get a bit more searching at this age and "why?" is frequently heard. Parents need to learn how to deal with embarrassing questions, as children often overhear things not intended for them. A simple answer, hiding any embarrassment is best, e.g. "What's a blow job?" could be answered with "It's a way people sometimes have sex".
Parents should try not to give judgemental statements as these may convey to the child that something is exciting or threatening. For example, if "What's a tart, Dad?" is angrily answered by: "That woman shouldn't be allowed in the street dressed like that." The child is far more likely to remember the anger and store up angry feelings against women who dress revealingly. An answer of "A woman wearing too few clothes in the street" will provide sufficient explanation at the child's level of understanding. Children at this age remember important lessons and emotional attitudes that stay with them into their adult life.
Sevens to nines
Although for most children pubertal changes occur from about 10 to 13 years, for some they may start as early as eight years of age. Starting periods or having wet dreams can be frightening to those children unprepared for it.
Children should have a grasp of the difference between right and wrong and they will want to know how this applies to sex and love. This is a good time to reinforce messages. It is also a chance to practise with role play about how to say "No" to things that they feel uncomfortable about, or don't want to do. Children will increasingly hear and see things which are not intended for their age group and will want to ask questions about them. If they are watching programmes or films, listening to songs, or reading material that contains sexual content, it is a good idea to talk about what the child makes of it, fill the gaps in their understanding and correct misapprehensions.
Box 2 contains a list of subjects that children approaching puberty should know about. Parents may have religious or other specific views about sexual responsibility, which they want to introduce to their children at this stage.
They also need to explain that for everyone, even if they hold different views, being responsible about sexual behaviour means:
_ Considering the needs and feelings of their partner
_ Discussing the relationship both partners want
_ Not having sex if your partner doesn't want to
_ Using contraception unless both people want a baby
_ Practising safer sex to avoid sexually transmitted infections.
Pre-teens and early teenagers
Teenagers tend to get lumped together, but there is a world of difference between a 13 year old, who is more like an 11 or 12 year old, and a 17 or 18 year old who is a young adult. Emotional and physical development varies widely, too; tailoring information to the individual's level is essential. Parents have to try to get a sense of where they think their son or daughter is in terms of their experience and maturity about sex. They need to try to remember what it was like for them - the agonies of not knowing how to behave, or fearing rejection, showing bravado, showing off and regretting actions. The older adolescents are, the more they become interested in sex and full of desire. (Never underestimate the power of sexual passion - remember Shakespeare's Romeo and Juliet and that Juliet was only 14.) This age group should already know about the mechanics of sex, but they worry about breasts, vulvas and penis size. They can only learn about emotional responses and social interaction by experience.
Some young people of this age are comfortable talking about sex, asking questions and telling a parent what is going on in their life. Others become intensely secretive, shutting their parents out. Adolescents may not ask explicit questions so parents have to pay attention to what is not being talked about, and how sex might be raised indirectly. Stories about something that happened at school, or a reaction to a particular class where sex may have been discussed, may be their opportunity to raise the subject. Adolescents use indirect questions - "How did you and Dad meet?" or "That girl shouldn't wear clothes that show off her fat belly" - and parents can pick up on these, asking, "Why do you say/want to know that?" to find out what is behind the question or observation. Adolescents are still in need of guidance and the fixing of boundaries. It is a balancing act at this stage, as adolescents swing from being the needy child to rejecting parents as irrelevant. Parents would not let a teenager start driving a car if they had never had driving lessons. Similarly parents have a responsibility to make sure their children know how to keep safe with whatever kind of sexual exploration they might be doing. If adolescents appear upset by parental pushiness, it helps to have a few books in the house that cover the basics and that they have access to a safe website to answer the questions that they do not dare to voice (Box 3). If parents feel able, they can let their adolescent children know where they can get condoms without asking for them (perhaps the car boot or a bathroom cupboard?).
School nurses, health visitors and allied health professionals should prepare themselves so that they are able to advise parents (and others) on where to obtain information, and how parents might go about talking to their children about sex and sexuality. They might want to look at liaising with parent-teacher associations, and with other organisations involved with young people such as the Scouts7, to help adults who are apprehensive about the subject.
Professor Gill Wakley MD FFSRH
Advisory Editor, Journal of Family Planning and Reproductive
Health Care; formerly Professor of Primary Care