Masturbation
Ilgi Ozturk Ertem
John M. Leventhal
I. Description of the problem. The World Health Organization (WHO) defines sexual health as the “integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love.” The clinician should view childhood sexuality as an integral part of child development as are physical health, growth, and other developmental domains. It is within this frame-work that the clinician should address parental concern with masturbation, one of the early manifestations of the sexual development of the child.
The term masturbation is derived from the Latin words for “hand” (manus) and “defilement” (stupratio). It is defined as a deliberate self-stimulation that results in sexual arousal.
At least since the time of Hippocrates (400 BC), masturbation has evoked negative attitudes within societies. For example, during the 18th century, two-thirds of all human illnesses were attributed to masturbation. Various treatment regimens, such as disciplining the patient, mechanical preventions, cautery of genitals, clitorectomy, and castration, were established and practiced until the mid-20th century. It is still true that parents’ and teachers’ responses to sexual behavior in children are largely influenced by cultural patterns. Some societies condone and encourage self-stimulation during childhood; others condemn it. In general, Western societies take a more restrictive view of masturbation. Childhood masturbation is not included as a specific psychiatric disorder in the Diagnostic and Statistical Manual of Mental Disorders (4th edition). The WHO places excessive childhood masturbation under “Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence” in the International Statistical Classification System of Diseases and Related Health Problems 10th edition (ICD-10).
A. Epidemiology. Masturbation is universal and may start as early as infancy. Normative studies of sexual behavior have shown that approximately 16% of children aged 2-5 years of both sexes masturbate with their hand, and that almost all boys and 25% of girls have masturbated to the point of orgasm by age 15 years.
B. Environmental, developmental, and transactional factors in etiology. Masturbatory activity has been observed in the male fetus in utero. In the first months of life, infants of both sexes learn to experience the sensations associated with diapering and the cleansing of genitals. A developmental progression toward adult erotic responsiveness proceeds from these early pleasurable sensations. This includes the differentiation and appreciation of genitals, inclusion of sexual parts in the body concept, “exhibitionism” to test adult reactions, mastery of a variety of self-elicited sensations, and the integration of sexual function into the emerging self-concept.
C. Signs and symptoms. Masturbatory activity in older children may resemble that of adults and involves handling or rubbing of genitals, sweating, flushing, tachypnea, and muscular contractions. Masturbatory activity in infants and toddlers typically does not involve handling of the genitals and may therefore make the diagnosis difficult. More typically masturbation in infants involves: stereotyped posturing of the lower extremities; pressing and rubbing on the perineum or suprapubic area; leaning the suprapubic region on a firm edge; stiffening of the lower extremities; rocking movements in various positions; symptoms of sexual arousal including sweating, brief bouts of crying, intermittent grunting, irregular breathing, facial flushing, and diaphoresis. These episodes may last from a few seconds to several hours. At any age, there should be no alteration of consciousness; the child should stop when distracted.
II. Making the diagnosis.
A. Differential diagnosis.
1. Masturbatory actions may be misdiagnosed as seizures because of the abrupt onset of the episodes, the tonic posturing, facial flushing, irregular breathing, and the child’s preoccupation. During masturbation, there may also be blank stares or tremulous movements. The child may resume his or her previous play or activity after the event
or may appear drowsy and fall asleep, mimicking children in the postictal phase. Tonic posturing with crossing of the thighs has been reported to occur as early as 3 months of age. Masturbatory activity in children has been associated with unnecessary investigations for organic disease such as seizures, epilepsy, paroxysmal dystonia, carcinoid syndrome, or urinary tract infections. The symptoms of masturbation also have been confused with abdominal pain or the “retentive” posturing that occurs in children who withhold stool. This is manifested as episodic tightening of the buttock and thighs, often accompanied by facial flushing and grunting.
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