24th November 2023

Puberty and Sexual Development

Puberty

Puberty can be an exciting yet sometimes tumultuous phase for children and their parents alike! Puberty refers to the stage in life through which a child undergoes both physical and emotional changes to reach sexual maturity. 

Puberty onset

The onset of puberty is denoted by the emergence of secondary sex characteristics such as testicular enlargement in males, breast development in females and increased body hair for both genders. The average age for males to begin puberty is around 12, while girls tend to begin earlier at around 11. However, it’s important to remember that it’s normal for puberty to begin at any point between the ages of 9-14 years in boys and 8-14 years in girls. On average, puberty lasts for a total of 3-4 years. 

What happens if a child begins puberty before the age of 9 in boys or 8 in girls? Well, this is called precocious puberty (PP), which essentially means early puberty. PP is comparatively more common in girls. Most of the time, there is no obvious identifiable cause; therefore, the condition is termed idiopathic precocious puberty. Rarely, medical conditions, including hormone disturbances, tumours, brain abnormalities, infections, or trauma, may be responsible for PP. Treatment typically requires medications that impede puberty.

Conversely, delayed puberty can occur if children pass the age of 14 without evidence of any signs of puberty. This can be caused by genetic variations, chronic illness, malnutrition or a variety of hypothalamic, pituitary and gonadal disorders. Thus, the evaluation and management of delayed puberty relies on the primary pathologic cause.

The Tanner stages of puberty

James Tanner, a British paediatrician, conducted a twenty-year study and, in 1969, identified five distinct stages that makeup puberty. These stages of puberty refer to the physical changes that occur during adolescence as a result of hormonal changes in the body. These changes are commonly observed in both boys and girls. It is beneficial to have an overall grasp of the Tanner stages, as these questions may appear in the MRCPsych exam.

One of the earliest signs of puberty in girls is the onset of secondary breast development, known as thelarche. Thelarche typically occurs in Tanner stage 2 and is followed by the appearance of pubic hair in stage 3. In girls, a growth spurt (a quick period of growth) typically occurs between Tanner stages 2-3, with most girls having completed their spurt by the age of 15 years old.

Menarche, or the onset of the first period, usually occurs in Tanner stage 4, which is marked by further breast development and the growth of pubic hair. It is worth noting that the onset of menarche is typically preceded by the onset of thelarche by approximately two years.

Pubarche, or the onset of pubic hair growth, is typically preceded by the appearance of the breast bud and occurs in Tanner stage 3. In boys, pubarche is often followed by the pubertal growth spurt, which typically occurs during stages 3 to 4 and is completed by stage 5 in most boys.

References

• Berberoğlu M. (2009). Precocious puberty and normal variant puberty: definition, etiology, diagnosis and current management. Journal of clinical research in pediatric endocrinology, 1(4), 164–174. 
• Palmert, M.R. & Dunkel, L. (2012). Delayed Puberty. The New England Journal of Medicine, 366: 443-453. 
• Tanner, J. M. (1992). Growth and development of children and adolescents: Normal patterns and abnormal results. In J. F. T. Bradley (Ed.), Pediatric endocrinology (pp. 3-18). Philadelphia: W. B. Saunders.

Sexual Development

Sexual development is a complex and multifaceted process that begins in infancy and continues throughout the lifespan. It involves a wide range of biological, psychological, and social factors that contribute to the formation of an individual’s sexual identity and behaviour. 

Freud’s theory of psychosexual development

Sigmund Freud (1856-1939) proposed the notion that all humans are born with an innate sex drive, otherwise known as the libido, that creates tension if it remains unsatisfied. To comprehend the development of personality in the early stages of life, Freud devised a theory which comprises five phases. Each of these stages can be distinguished by certain gratifications and conflicts. Infants first experience a state of self-absorption, gaining pleasure from bodily activities, which is followed by an emergence of love towards objects and individuals outside of themselves. If a child is not able to work through the challenges of a certain stage, they can become hindered in psychosexual growth, which can result in the development of certain traits in adulthood.

It’s important to note that Freud’s theory of psychosexual development is controversial and has been criticised by many modern psychologists. It should be understood as a historical perspective on human development rather than a scientifically validated theory.

References

• West, D. J. (2000). Controversies surrounding Freud’s theory of infantile sexuality: Evidence-based reflections. Archives of Sexual Behavior, 29(6), 559-573.
• Freud, S. (1905). Three essays on the theory of sexuality. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 7, pp. 125-245). Hogarth Press. (Original work published 1905)
• Johnson, R. M. (2019). Freud’s psychosexual development theory revisited: Relevance for contemporary psychoanalytic psychotherapy. Psychoanalytic Psychology, 36(2), 109-119.

Gender Development

Gender identity and gender behaviour

We’ll start by defining some key concepts before looking at gender development in further detail. 

• Gender identity – An individual’s own understanding and perception of their gender. 
• Sexual identity – In contrast, it is based on a person’s sexual characteristics, such as their external and internal genitalia, hormonal characteristics, and secondary sexual characteristics.
• Gender dysphoria – A ‘disconnect’ between gender identity and sexual identity, and it is more common in boys than in girls.
• Gender roles – Social expectations comprising the generalised patterns of activities, looks, and behaviours associated with being a man or a woman. These roles can either match or contrast with a child’s gender identity.

There are many different factors which influence a person’s gender identity. These include chromosomes, gonadal endowment (testes/ovaries), internal structures (uterus/prostate), external genitalia (penis/vagina), hormonal balance, the gender assigned at birth, and the response of parents to the child’s assigned gender.

Milestones of gender development 

By the age of ten months, babies are already capable of associating certain objects and items with gender roles, and by 18 to 24 months, they start to identify between genders and use gender labels in their speech. In addition, by approximately 18 months, most kids become aware of their own gender. At around five to six years of age, children usually make their gender identity known by declaring whether they are male or female. Throughout their development, it is typical for children to explore and experiment with different gender expressions and roles.

Kohlberg’s classical stage theory

According to Kohlberg’s (1966) classical stage theory of gender development, children can identify their gender by 2 years of age, understand its stability by 4, and comprehend its constancy and independence from external features by 7. However, we now acknowledge that gender identity encompasses an individual’s recognition of gender affiliation, personal compatibility with their category, pressure to fit in, and perspectives on gender groups. The formation of a transgender or gender nonconforming identity involves intricate collaboration of phenomena throughout time. The acknowledgement of fluidity and variability in gender identity is becoming more prevalent.

Gender dysphoria

Gender dysphoria is defined as a persistent discomfort and sense of inappropriateness regarding one’s assigned sex and is more commonly seen in boys than girls. In most cases, gender dysphoria dissipates in the years prior to puberty. However, in a minority of cases (15%), the dysphoria may continue into adulthood.

Physical and psychiatric presenting symptoms of gender dysphoria can include a preference for friends of the opposite sex, preoccupation with wearing the opposite gender’s clothes, refusal to use the bathroom in the expected way, the belief that they were born in the wrong body, requests for medications or surgeries to change their physical appearance, and other modifications to the body such as mastectomies and testosterone use for women, and electrolysis, oestrogen use, and genital surgeries for men.

References

• Zucker, K. J. (2017). Epidemiology of gender dysphoria and transgender identity. Sexual Health, 14(5), 404-411. 
• Blakemore, J. E. O., & Hill, C. A. (2008). The child’s understanding of gender roles. In M. Killen & J. G. Smetana (Eds.), Handbook of moral development (2nd ed., pp. 357-381). Psychology Press.
• Martin, C. L., & Ruble, D. N. (2010). Patterns of gender development. Annual Review of Psychology, 61, 353-381.